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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 6� � d¢�'� <br /> _ (For Non-Transferable;Revocable;-and Suspendable) 1 SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 1p,,Mereby made to arry on busin s in the jurisdictional area of the San-JWquin Local Health District <br /> to Business Name A) ° Address ��'' �� 6 '� , <br /> cOwner Address <br /> J Firm Partners, Addresses andelephone Numbers <br /> t a Business Telephone No._. � ®B - Emergency Telephone No. <br /> Contractor Licence No. �. Z <br /> L Applicants Name (Print) Title d Date- Z '� a --7f2-- <br /> f Please check Applicable Category (1-7)and Fill in the Required Inform tion <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, 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 Lion Test Date/Time _ <br /> 4. L9 SANITATION PERMIT , t .. <br /> Job Adclms Location 4J O-a••=a.s_ Y <br /> Owner --Ad-dress �'-o-i- <br /> ❑ SEPTICANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ PACKAGE PLANT, - t <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW EP R ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br />'r Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name f Where Certified i.. r <br /> Plant Location _ <br /> I 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/AmounVMo. s <br /> Home owner or licensed agent's signaturecertities thefollowing:"I cert ify that in the performance of the viork for which this permit is issued,f shall not employ any pens an <br /> in such manner as to became sub;ect to workman's cotnpensatiori taws of Gatifcrnie." <br /> Contractor's h€eine or sub-cerrtraetinq signature cert9lies.+*.!Mowing:_1 cerfiiy that in the performance ci the work for which this permit is issued,I shag <br /> employ persons sut?ject to workman s compensatioti 1avis 3t Calitor�id." <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, and r s and regulations o San Paquin Loeal:Health District. <br /> APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY. <br /> Fee Is Due: ❑ ANNUALLY -[JPER UNIT' ❑ PER SITE e ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 RJReceived By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED ' <br /> ... _ .. ...... DATE DATE REMITTED' <br /> AMOUKA ! <br /> FEE - S <br /> L655 + <br /> PRORATION i' - • - � -, � _ a <br /> I: PLUS r <br /> PENALTY - .<_ -Aj <br /> ,OTHER r <br /> 1 _ ; OTHER , <br /> Received by Date Receipl No. Permit No. Lissuahce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />