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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocatike,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is h reby made t car on business in the jurisdictional-area of the San Joaquin oval He lth District <br /> ' YZ R <br /> rBusiness me (D ) •-•• - ��Address .3 � ,:_�.-,• _ <br /> z Owner , .: Address <br /> ' a <br /> R Firm Partners, Addresses and Telephone Numbers �l <br /> Emergency Telephone <br /> CL Business Telephone No.: S• 5.2., _^ No. v ` <br /> Contractor Licence No. S'. <br /> : � .- 1 i> •., i Title V�cg -r„c A ..t. Dated a <br /> LApplicants Name (Print) <br /> Please check Applicahie Category,(1-7)and Fill,In•the Required.lnformatton, rr, ;•, ^� `, p 4i� , y*� ,, I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For'July 1, - --•June 30, 19- r 6 'Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. # CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,=Weights & Measures No. p� <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ; <br /> For July 1, June 30, 19 f . <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 /> _:.. _ <br /> Tes Location Test Date/Time <br /> 4. SANITATION PERMIT " { <br /> 4 <br /> Job Address/Location .4 <br /> Owner t c �� -'-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 /> ' Stora a/Cleanin Location(s), t 1 <br /> No. of Units 'Equipmentg 9. t <br /> € 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> here Certifiedht <br /> Operator Name <br /> Plant Location r . <br /> Plant Capacity No. Units Served <br /> 7.- 0 LAUNDRY For'July 1; -#June 30, 19 -� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- i <br /> ❑ qpY CLEANING, Chemicals Used/Amount/Mo. ; <br /> ome owner or Ilems9d agent's signature r,Brflfies the ivslowing:1 certify t':: ,hepertorrrvihich this permit is Issued,t shall-not employ any person <br /> in such manner as To beeotrte S1UWect to wafkman•s corupersatiort lavas t t Calif2r;+s, ' <br /> Contractor's hiring a* seb-contracting signature certifies the fntlawing' 1 certify that in the performance 0-the work for which this permit is issued,f shall <br /> employ persons subfe0l.to workman's compertsationt.laws of California." <br /> Y 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 nd rules nd regulations of the San Joaquin Local Health District. # . <br /> F' n <br /> APPLICANT'S SIGNATURE X �1 <br /> 4 <br /> -- i. FOR DEPARTMENT USE ONLY t y- <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT: ❑ PER S1TE ❑ 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 /> 'FEELESS <br /> PRORATION <br /> PLUS - (7•'+ .. <br /> PENALTY - <br /> OTHER - <br /> OTHER ` <br /> I Received by , Date Receipt No, Permit o. tssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:�• ENVIRONMENTAL HEALTH PERMITlSERVIdESL1601 E.HAZELTON AVE.,P.O.Box 2OD9' STOCKTON,CA 95201' <br />