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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. L <br /> APPLICATION <br /> F (For Non-Transferable, Revocable, and Suspendable) / f "- <br /> SEPTAGE�^�.;" "� <br /> ENVIRONMENTAL HEALTH_ PERMIT ` <br /> LIQUID WASTIE -. `"' <br /> Applicat''�on is h eb made t ca on buslne s i ie jurisdictional area of San J quin Local Health District p r <br /> ,n Business Name (DBA)1,� ;� _ -��� ' Address Q, I �- le a o� <br /> aOwner h ��" Address _ 1 <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. '~�� � - Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title "y" •pate <br /> Please check Applicable Category (1-7) and FIII 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. License Renewal No. <br /> Capacity w ..fir 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 4 R.S. or R.C.E. No.r 4 <br /> Tes"Lucaion Test Date/Time <br /> 4. SANITATION PERMIT T x <br /> Job Address/Location Z <br /> Owner 74 O Address ;C'c.5;&-fa� <br /> ❑ SEPTIC TANK—, ❑ CESSPOOL.. EACHING FIELD AaEEPAGEPIT ❑ PACKAGE PLANT---�—M a.. <br /> ❑ <br /> PERMANENT j ❑ TEMPORARY ❑ NEW �EPAIR OTHER t.,,�, <br /> 5. ❑ CHEMICAL'TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units ~ '- Equipment"Storage/Cleaning Location(s) 1 ) _ Ik- <br /> d�..4. _ <br /> 6. ❑ PACKAGETREATMENTPLANT For July 1, -June 30,19 }- 4 <br /> Operator Name 5 -- - .. .__ --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. 3^� <br /> Han,eowne�brlicensed agent'ssigmtureeertifiesthefollowing:1 certify that inthe performance <br /> .at tfiework for which this permit isissued,Ishall not esnploya pers <br /> in sock manner as to become subject to WUrkmali s c4rnpensatioti laws of CaiiforMa ; 7 <br /> Contractor's hiring or subcontracting sigrieture certifies the fallovring: i certify that in ine perlooiance Q!th ,work for which this permit is issued,I shall <br /> employ persons subject to wflrkman s compensat°wn laws of Calift?tnia,"'� _ �- <br /> I hereby certify that I have pre ed this application and that twork will be don in accordance with San Joaquin County <br /> ordinances, state laws, and r es ions o-&e San J q LocMI th Dis riot. - <br /> f <br /> APPLICANT'S SIGNATURE X <br /> `t FOR DEPARTMENT USE ONLY <br /> AN <br /> Fee Is Due: ❑ NUALLY "'`- C1PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - _. ..._.. REMIT <br /> t BILLING REMITTANCE $ <br /> BASE? EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> { t AMOUNT <br /> FEE <br /> LESS r [ <br /> PRORATION '` ' Z. <br /> PLUS t # <br /> PENALTY <br /> OTHER <br /> OTHER } !' I ki _4 <br /> 1 �d . <br /> Received by Date Receipt No. Permit No. 4 s nee ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SE1 E.RVICES 160H AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />