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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 /> Application is reb made to car on business in the jurisdictional area of a San Joaquin Local Health istrict <br /> F Business Name (DBA) A• /� RIS.t+ I_,.'�e�NS Address�Q• K 14%-r-)- ��LSI 9'577-01 <br /> aOwner Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ZS <br /> Applicants Name (Print) ISI—A.to L��l '� ,5LL�5 Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. r <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i. <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 Address/Location 13p6� kc,. <br /> �PE <br /> er Addre <br /> PTICTANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKA E PLANT <br /> ERMANENT ❑ TEMPORARY ❑ NEW 5zREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 0 r <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 <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 /> Home owner ofHcensedagent's signsturecertMosthofoflowing:1 certify that irt the Performance ofthawofkforwWchNspermit isiseued,ishallnotemployanypers.:^ �! <br /> In such manner as to become subject to Workman's compensation laws of Ca fornia.' R <br /> eontracto so hiring or euwkmaifa... *nstitne ew"fiss tM fO#OWftg: .1 t>etiily tat In The performance of the work for which this permit is issued,l shall y <br /> EQY persons subject i4 wprlcman's compensation laws of California'. <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ul and re at on, the San uin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> LESS 1 <br /> PRORATION 1 <br /> PLUS•" a ���777� <br /> PENALTY <br /> OTHER ]`\� <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ce le Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />