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Applications Will Be Processed When Submitted PFoperly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable; and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT, - <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I. .. p. STZ <br /> F Business Name (DBA) -�, A N. .,� ;Address . <br /> a Owner Address <br /> i <br /> Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. Emergency Telephone No. <br /> i <br /> Contractor Licence No. <br /> a <br /> Applicants Name (Print) - 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) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 119 <br /> No. of Vehicles Stored• 4 <br /> No. of Chemical Toilets Stored <br /> v. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name 4ji� _ R.S. or R.C.E. No. <br /> Te Location I J Test Date/Time <br /> 4. SANITATION PERMITi �! _ <br /> Job Address/Location SO�� 1��1�s D <br /> Ow er _ Addres�cs,r�I� OHO m L.O p <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ,IfiEEP.AGE PIT ❑ PACKAGE PLANT <br /> ❑ OTHER pJ� <br /> PERMANENT ❑ TEMPORARY{t 1 NEW r ❑ REPAIR -pro) <br /> 5. ❑ CHEMICAL TOILETS For July 1,"=Ju6 30, 19 <br /> Type Construction Disposal Site ' <br /> No. of Units :_ Equipment Storage/Cleaning Location(s) k't .- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, June 30, 19 �' � <br /> Operator Name " re Certi led I <br /> Plant Location N <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1!--June 30, 19 { ,, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Mor'e Than 1,000 Sq. Ft. r <br /> ❑ Y CLEANING, Chemicals Used/Amount/Mo. <br /> nD^1e rorUef-sedagent'$signaturecertifiesrhefollowing:1-r:ertitytthatihtheperformanceofthe work for which this permit isissuAd.lshaftnot employ anyperswi <br /> iR 5tiC11 manrtec RS tU become.SI1bjECt t(:'NGTk:{Is,15 COt t�v 5 JtiJT4 taYJS of{HiitO'Rl – - <br /> Connector's hiring or sarh-cantimming sfgnitture certifies t1w *ailowing. r'i Cet'tify that In tits performance of the v ork for which this permit is is ed,i shall <br /> employ persocs subject to wofknian's cemp2trsation laws Ji Calilomia." ism <br /> ed, <br /> certify that I have prepared this application and tha A a work will be done in accordance with San Joaquin County <br /> ordinances, state laws les and r ulations. the a J q Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> .a FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 1:1ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH [3January 1 &Received By January 31 ❑ July 1 S Received 8y July 31 <br /> `11 rREMIT <br /> BASE EXPLANATION BILLING REMITTANCE �j� $ AMOUNT DUE CHECKED <br /> DATE n DATE REMITTED AMOUNT / <br /> -FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. P emit Notssu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES Y 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />