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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the'jurisdictional area of the San Joaquin Local Health District. <br /> t <br /> HBusiness T.L(PtA <br /> 4Owner Address O j� �. Tt'1 a�4 4 1 �4 1't <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> 41 Applicants Name(Print) -Title Date <br /> Please check Appiicable Category (1-7)and Fill in the Required Information < i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites ; <br /> { Ly <br /> Description(Make/Yr., Color) E ` <br /> Serial No. CAL. License No.- } " CAL. License Renewal No. • �l <br /> 3t f. <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 F <br /> R.S. or R.C.E. Name -' !' : t R.S.or R.C.E. No. <br /> Test Location i IsTest Date/Time <br /> 4. ❑ SANITATION PERI . ) <br /> Job Address/L402 bon 11 s + ~�sti <br /> � <br /> Owner LL �<< Address ~ <br /> L�EPTIC TANK 1:1 CESSPOOL EACHING FIELD�O SEEPAGE PIT ❑ PACKAGE PLANT- <br /> ❑ PERMANENT ❑ TEMPORARY geNEW � ` I❑ REPAIR ❑ OTHER <br /> 5. 1:1 CHEMICALTOILETS For July 1,,-June 30, 19 1 ._ 1 ' <br /> Type Construction ^�a Disposal Site `N <br /> No. of Units Equipment Storage/Cleaning:Loc`ation(s) <br /> +�v _ <br /> 6. El PACKAGE TREATMENT PLANT For July 1:,,-June 30, 194. <br /> Operator Name � r `4 r=,. 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 1,004 Sq. Ft.", <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. I t <br /> Ffar�cownerariics+ne�us elt'Sw nnherers !iSd-?s'the'trfloyrEn ;"Irert;lvthtitinihepetfnrmaRCeoIthe Luorkforwhichlhispermit isi;sued.Ishall not employ any persan <br /> In such mariner as to bectsmr subt:,ci fo Wxkman's rairpen5atior laws csf Ca!ifnrnla .L 1%. . <br /> Conlractor;S hirino or sub-contraa;:iriet kign?turo ceraif2e-, the fntloehrtg: "lrCer,ify il1at in the performance of the work for v�hittt_lhls permll IS 4ssued,f shall <br /> employ pf,rsons subject to v/crknnari's corripensaiion lays of California." <br /> I hereby certify that I have prepared this'appiic`afiori'and that the-wo will be done in accordance with San Joaquin County <br /> ordinances, state laws, and-rules and,re lations of the n aqu' ocal Health District. M <br /> APPLICANT'S SIGNATURE X - <br /> - FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY I❑ PER UNIT ❑ PER SITE ❑ EACH I ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ?.E REMIT - - <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE - F DATEB'EMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION �" f <br /> PLUS _ - <br /> PENALTY -r1 <br /> OTHER <br /> OTHER <br /> Received by Ii Date I Receipt No. Permit No. issuance Date., Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />