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Applications Will Se Processed When Submitted ProperlyCompfetea tiesure Iaalgn 1nv„r,N•...a.•., <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGF + <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTEf <br /> Application is hereby made to carry on busin in the I ri dictional area of the n J quin Local ealth District <br /> h <br /> BusinessName (DBA) LE~E LA Address <br /> ? Owner ��. Address <br /> a <br /> Firm Partners, Addresses and le one Numers <br /> CL Emergency Telephone No. <br /> CL Business Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) <br /> Title <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 4 <br /> CAL:.License Renewal No. <br /> Serial No, CAL. License No. J <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PE IT <br /> Job Address/Location <br /> Owner �� �' '�' Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL --JrL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ' ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 <br /> I Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1.,-.June 30, 19 4 <br /> c <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> Home ovvner or licensed agent',,signature cerfliloe tha folh+urillg:"1Tertily tt at io the perfmmancoof thework for which this p"It is issued,)shall not employ any person <br /> in such manner as to become subject to workman's cornpematior,laws of California-' <br /> Contractor's hiring or sub-contracting seg:ratl.l.w3 certiries the toilawing: "f certify that in the performance at the work for which this Qermit is i5stted,l shall <br /> employ persons sub! o workman's compelsallon laws of California- ' <br /> I hereby certify;at I e prepared th application d that the work will be done in accordance with San Joaquin County <br /> ordinances, state s, d les�nclrae�5OZ <br /> rHealth District. <br /> i <br /> v <br /> APPLICANT'S SIGNATURE X <br /> -- FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY k0'0 PER UNIT .v ❑ PER SITE D EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> .4-� BILLINb REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEEVV— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER �e <br /> OTHER <br /> Received y Dat Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITIS€RVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />