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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I it APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application isgherymad o ca 4n bu s i h risdictional area of the S a in al Heal h 'stnc <br /> O Business N DBA) u— Address �~ <br /> z Owner £ I' Address <br /> X <br /> Firm Partners, Addresses and Telephone Numbers <br /> a (0 Telephone No. (0 k, 43 Emergency Telephone No. <br /> Contractor Licence No. 7�� �— <br /> L Applicants Name (Print) <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. LiCcnso ReRe+�`al No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking-Address ' <br /> x 2. ❑ PUMPER YARD , <br /> For July 1, June 30, 19 <br /> No. of Vehicles: Zred_ <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 /> 4S Test Location Test Date/Time <br /> f 4. SANITATION PERMIT - <br /> f Job Addre Location ;Lb. "" <br /> Owner Address 23 <br /> 11SEPTIC TANK ❑ CESSPOOL ACHING FIELD [S'SEEPAGE PIT ❑ PA KA PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site f <br /> No. of Units equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANTI For July 1, -June 30, 19 74 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> �1 No. Units Served v <br /> Plant Capacity <br /> r 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 /> Rome&Amw or licensed egbrrt's signature certifies th�otlowwing:'1 certify that in theperfonnance of the work for which this permit is issued,I shall not employ any persr <br /> in such manner as to become subject to workman's compensatiun lass of California." <br /> Contractor's hiring or subcontracting jignature terrifies tho following: "I certify that in the performance of the work.for which this permit Kisseed,I shall <br /> employ persons subject to workman's campensatir,n Parrs uf'Cahtornia`- y =� <br /> I hereby certify that I have prepared this applic' n and. at the work will be done in accordance with San Joaquin County',-- <br /> ordinances, <br /> ounty" ,aordinances, state laws, a u e and r tion f S Joaquin-Local Health District. <br /> APPLICANT'S SIGNATURE X j 4— <br /> FOR DEPARTMENT USE ONLY - <br /> Fee IS DUs: ❑ ANNUALLY PER UNIT PER SITE 0 EACH ❑ January 1 &Received 9y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECK D /} . <br /> -.DATE --DATE `REMITTED s A OU <br /> FEE l 1 - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> k OTHER- <br /> OTHER <br /> ' Recei t No. Permit No. Issuan Date - Mailed Delivered <br /> Received by Date P <br /> r APPLICANT—'RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Bax 2008, STOCKTON,GA 95201 <br />