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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> App]Ica 'onis hereby made to carryonusiness in th urisdi ti n of the San Joaquin Local H aith Di tract <br /> O Business Name (DBA) L- ess <br /> a Owner Address ' <br /> J Firm Partners, Addresses and le one Numbers <br /> cL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - <br /> L Applicants Name (Priht) Title ate r r <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1: El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 r <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. . CAL. License No. + i CAL. License Renewal•No.. I <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.O Chemical Toilets Stored – --� --- --- -»-- -- __ <br /> 3. ❑,PERCOLATION TEST 'I <br /> R.S.or R:C.E; Name 1 <br /> P.. r r ,,. y R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 1.1 SANITATION PERMIT <br /> Job Address/Lo ation _ <br /> Owner— C Address <br /> ❑ SEPTiC TANK ❑ CESSPOOL f_N <br /> EACHING FIELD., SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY EW _ EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL'TOILETS For July 1, -June 30, 19 <br /> Type Construction{ Disposal Site <br /> No. of Units Equipment Sto?age9Cleaning Location(s) f <br /> 6. ❑ PACIKAGE TREATMENT PLANT�For July 1, -June 30, 19 <br /> Operator Name Where Certified € <br /> Plana Location _ x <br /> Plant Capacity, t– av <br /> 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> degrrrtrRs3erraturece.sFtiesrte,roftowing:"lekrtlfyfl►atintheper#afmanceofthetuorkforwhichft ermitisIssued,Ishallnotem I any4persofoi <br /> iia$Itd4lrl�mer asto become subject to workman,,conpensafis"lasts ofGa=fam:13.' P If oY <br /> Ufa tli+4 or Rab-eantruetilrg aignat�ro c�retFfas tf�e faHowxW- "I certit that in the Per of the work for which this ermtt is issued,t shall <br /> I'p sutljef tb+Aerklnan's Compensation fa s�oT Gat�osia y P <br /> 1 hereby certify th have'pra"red IN tion an t at the wo will be done in accordance with San Joaquin County �Q <br /> ordinances, state law , a ru s an reg ]a n f t oaquin c Heal District. <br /> 3 <br /> APPLICANT'S SIGNA <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY '` 1❑ PER UNIT ❑ PER SITE 13 EACH ,J ❑ Janus 1 &Received 8 Januar 31 <br /> _ r)` Y Y ❑ July 1 &Received By July 31 <br /> --REMIT <br /> BASE# t BASE t EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> {{} . DATE DATE REMITTED AMOUNT <br /> FEE <br /> 1 LESS <br /> PRORAI-ION r : <br /> PLUS r <br /> PENALTY <br /> OTHER ) <br /> r f.*X <br /> OTHER <br /> Received by Date - eceipt No. erm o. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />