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Applications Will Be Processed When Submitted Properly 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 /> r,� R <br /> Application ishereby made to carry on busine in the jurisdictional area of the San Joaquin Local He th 'stri t <br /> Business Name (DBA} 11 <br /> , �n "�e y)-C —Addresss <br /> a Owner Ile Xb Address JJ <br /> Firm Partners, Addresses and Telephone Numbers l <br /> CL <br /> Business Telepho a No. Emergency Telephone No.. _ <br /> Contractor Licence No. <br /> Applicants Name (Print) ,e Title Date <br /> Please check Applicable Category (1-7)and Fill in the Re fired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION{FOR EACH VEHICLE) --- j <br /> For July 1, June 30, 19 Disposal Sites I <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, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. KSANITATION PERMIT <br /> 'Job Addr ss/Location <br /> ^� 1 <br /> Owner e o Address <br /> ❑ SEPTIC TANK ❑ CESSP OL LEACHING FIELD 4-SEEPAGE'PIT ❑ PACKAGE PLANT r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑%REPAIR r <br /> ❑ OTHER - <br /> ;r <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Site <br /> Type Construction Disposal _ - <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> Ishall 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19Operator Name <br /> Where CertifiedPlant Location <br /> Plant Capacity. No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 'SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq" Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Homo owner orlfconsedagenvssignt,recert3fiegthefollowieg:'Tcerlifyylhatintheperformanceoftheworkforwhich*ispermitisissued,Ishallnotemploin such manner as to become subject to workmai;'s c=pensatiou laws of California.Contractor's hiriN or s ib-contracting sign9tura certifies *tie fogaMing:: l certify that in the performanceof the work for which th"is permit is issued <br /> employ persms subject to workman's,campensation laws of Catifornia,' <br /> I hereby certify that I have prepared this ap 'ca and t t the work will be done'in'accordance with San Joaquin County <br /> ordinances, state laws, and les and regu n_ the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I' FOR DEPARTMENT USE ONLY <br /> 4 i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JuEy 31 <br /> REMIT <br /> a BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE�� RATE. REMITTED AMOUNT <br /> tial so 0 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY - <br /> .OTHER <br /> OTHER - <br /> —!t),SY5, v Clams <br /> Received by E Date. Receipt No. Permit No. Issu ce Uaid Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br /> f <br />