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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - * (For Non-Transferable, cable,'and Suspendable) <br /> Revo <br /> SEPTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica on is hereby made o carry on business in th 'urisdi ti nal a.Lea of the San Joa On Local Heal h District. <br /> FBusiness Name (DBA) ess b <br /> a Owner . .. Address <br /> .*. .. <br /> j Firm Partners, Addresses anlTel� ne u bis <br /> Q. Business Telephone No. `�� �� Emergency Telephone No. r~ ~f <br /> Contractor Licence No_ <br /> ;-. <br /> L,Applcants,Name:(Print)Ff Title, _ ate <br /> Please check Applicable Category(1-,7)and Fill-in the Required information <br /> C,1._-❑TPUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> w <br /> For July 1, M June 30, 19 _ Disposal Sites - - - <br /> Description(Make/Yr., Color) •_«} ` / _i J t'`� _� ',cam Ir: R <br /> Serial No. CAL License No. CAL. License Renewal No. <br /> e--^G'al:-Weights'R Mea5ulres'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 Stoked I <br /> 3. ❑ PERCOLATION TEST- t <br /> R.S. or f <br /> R.C.E. Name i I or R.C.E. No. . <br /> Test.Location ITest`Ct'ete- ime E <br /> 4. ❑ SANITATION PERMIT i { <br /> Job Addres ocation <br /> Owner - Addr s <br /> - _ <br /> 'i <br /> ElSEPTIC TANK. C1 `"'-CESSPOOL `�❑ LEACHING FIELD ,EPAGE PIT- ' ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEtMPORARY ;113' k EPAIR 5-} -E OTHER <br /> 5. 13CHEMICAL TOILETS For July 1, -June 3D; 19 d � <br /> i" <br /> Type Construction ) i Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) I I <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -Ane 30, 19 <br /> Operator Name # ( ' Where Certified) <br /> Plant Location <br /> Plant Capacity `a—NoUnits 5ery <br /> 7. ❑ LAUNDRY For Jul),1, -June 30, 191 ' f—t .TTS <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemi6als Used/Amount/Mo, <br /> I <br /> Hama owner orlicensed a9cnt'saignatur®aortifitr <br /> ,the inll w;n9;•`Ice"tifv!ha`intheperfarmanceofthe work for which this permlitisissued-tshallnotemploylanyperscn.T1 <br /> in such manner as to become subject W workman's crmpe3sa*}ton laws of alifcrni:' .�� <br /> Contractor's hiring or sub-caatrueting Signature.cerlitlus the toitaxmlg 4't Cel lit`y that in ttie p6rformanpe of the work fol.which If1i5 permit is issued,!shall <br /> emptoy.persons subject to Ivorkman's compensation laws of California:' �` <br /> here}a}LGe.I ify that l In ve prepare t is ap licatio a d that th rk will be done in sccordahce with Sari 'Joaquin County , <br /> ordinances, state - ules and re ula ib s of a an Joaqu L c Ith District. i <br /> 1 w I <br /> APPLICA'NT'S SIGNAT <br /> -FOR DEPARTMENT USE ONLY r <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT 11 PER SITE ❑ EACH' ❑ January 1 &Received By'January 31 ❑ July 1 &Received By July31 <br /> r : REMIT <br /> BILLING REMITTANCE - AMOUNT DUE CHECKED j <br /> tf BASE EXPLANATIONS t k t <br /> DATE- DATE REMITTED 't - ti 'AMOUNT <br /> FEE _J j <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> '4 <br /> OTHER [� -, _ <br /> OTHER <br /> Received by <br /> _ ate .Receipt No. i Permit No. Issuance Date Maned Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 1�1'1 ' Vii. <br />