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Applicatiors Will Be Processed When Submitted Properly Completed. Be SureTo Sign ineAppucauvn. <br /> APPLICATION <br /> (For Non-Transfe;rableRevocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT, <br /> LIQUID WASTE <br /> Application is WAV2y made t arryyo business in the jurisdictional area of thesSan.Joaquin Local Health.District r,.y <br /> U) Business Name{ A} Address <br /> aOwner ,V <br /> J Firm Partners, Addresses and Telephone Numbers <br /> l a Business Telephone No: r r. Y q n Y Emergency Telephone No. <br /> Contractor Licence No. . <br /> Applicants Name (Print) a .. Ti, , Date s } <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites - .. <br /> For July 1,.. June 30, 19= P <br /> Description(Make/Yr.,Color) ;i <br /> CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Ca acit -- �-�"'�""'�u` .,Gal:;Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD v <br /> .For July 1, - June 30, 119- <br /> No. <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST -_— _. . - <br /> R.S. or R.C.E. Name k I R.S. or R.C.E. No. <br /> Test L cation j Test Date/Time <br /> 4. ;ANITATION PERMIT <br /> Job Address/Location '� <br /> Owner Addresses *� <br /> ❑'SEPTIC TANK ❑ CESSPOOL Z;R. .EACHING FIELD" El SEEPAGE PIT C3 PACKAGE PLANT - UQ <br /> r ❑ PERMANENT ❑ TEMPORARY ❑ NEWEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, '19 <br /> Type Construction A Disposal Site <br /> No. of Units r Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT'PLANT For July 1, -June 30, 19 <br /> u <br /> Operator Name <br /> Where,Certified <br /> ` <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, ,June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq:FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Homeowner ariicensedsgent'sGiBneturcoe_rtiiieathe€oltowing:1certiivfl?stir,`. eperfor, ancsof`:hc1 orltferl°ihichthis permit isissued,lshallsrot"emptoApersoil <br /> in such manner as to become subject to workman's compensation laws of Ca(ifn_ri,ia <br /> Contractor's hiring or sub-contracting signature certifies tit.'. following: 'I certify"t11at in t!c uerfarmal ce 6f the work for which this permit is issued <br /> employ persons subject to workman's compensation laws of Calitofnia.- <br /> " Thereby certify that`I have pre ared this application and that the work will be"done in' accordance with San Joaquin County <br /> ordinances, state laws, and r s nd reg ations he San Joaquin Local H alth District. <br /> APPLICANT'S SIGNATURE X <br /> _ FOR.DEPARTMENT USE ONLY_ <br /> Fee Is Due: ❑ ANNUALLY�i ❑ PEA UNIT ❑ PER SITE ❑ EA CH ❑ January 1 &Received By January 31 " ❑ July 1 &ReceiveRdEMIITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE YREMITT D AMOUNT <br /> 163 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �I <br /> OTHER l <br /> OTHERt, ± <br /> 3_ ' <br /> IL <br /> .Received by - Date - Receipt No: Permit No. Issuanc Dat Mailed Delivered <br /> `- APPLICANT-RETL/RN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br /> II <br />