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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 /> I LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin L cal Health District <br /> Business Name {DBA} o�++�eS 4 y� � Address . f2o c�TZT A� <br /> z Owner <br /> J Firm Partners, Addresses and Telephone Numbers JIr - 3 9Zl - - <br /> $ Business Telephone No. Emergency Telephone No. - <br /> Contractor Licence No. <br /> Applicants Name (Print) �' Title Date a <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, - June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) a <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. ❑ SANITATION PERMIT Afr <br /> Job Address/Location . C -3 3 14 N j.*° X 574= <br /> Owner 04-0 H D0,4 CA Address, <br /> ❑ SEPTIC TANK CESSPOOL ❑ 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 /> Operator Name Where Certified <br /> Plant Location t <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 /> j <br /> Ffiomeownerorlicensedtlgent'aslgnsturecortlfiesthsfbttowEnc_r""1rertifvfh�tFtstt�t:er'ntmartCe�thewarkfor whiGfit3►isp@rmitisi5suedlshaltnot employ any Person <br /> in such manner as to become sub}eel to workman's compensation tavrt-of CaYiIwi:i t <br /> Contractor's hiring or sub•eontmoting signature certifies the following: 'i certify that at t1E performance of thg wotk fel which this permit is issued,I shall <br /> employ persons subject to workman's WfnperisatiGfl taws of Catitornia" <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws; u1 s an regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> $) -a�3A / <br /> FOR DEPARTMENT-USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT• ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ Ju$y 1 &Received By July 31 <br /> i. 1 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ? i q s <br /> LESS r <br /> PRORATION T <br /> PLUS - 4 .. <br /> PENALTY <br /> OTHER <br /> OTHER <br /> V )4, <br /> Received by Date Receipt No. Permit No, - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL REALTH PERMIT/SERVICES T 1601 E.HAZELTON AVE.,'P.O.Box 2009 STOCKTON,CA 95201 <br /> f <br />