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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION t <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h ebade o%%r lon?siness in the jurisdictional area of the S J quin� I HealtYl 4is I. <br /> Business Name (DBA) (" ` ry "�JL-j fl,l <br /> z Owner. -. _ Address <br /> Firm Partners,Addresses and Telephone Numbers y <br /> a'Business Telephone No. L4 Emergency Telephone No. <br /> j Contractor Licence No. <br /> .,L Applicants Name (Print) - - u ,Title r �-Date <br /> _ <br /> t, 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) i - <br /> Serial No. CAL. License No. CAL. License Renewal No. �1�1 <br /> Capacity, -...w - Gal., Weights &•Measures No. <br /> Equipment Parking Address r'% ' <br /> 2. ❑ PUMPER YARD 'i. <br /> S iFwk1 i . <br /> For July 1 June 30,-1-9 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br />' R.S.or R. Name R.S.or R.C.E. No. <br /> Test L ation } µ Test Date/Time <br /> 4. SANITATION PERMIT ) <br /> Job Address/Location f. G 4V1-w <br /> Owner a Q.'4 $ � Address QG <br /> ❑ SEPTIC TANK' ❑ CESSPOOL L ACHING FIELD T_.❑, 5E f?IT_;.0 PACKAGE PLANT ' <br /> ❑ PERMANENT ❑ TEMPORARY EW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL'TOILETS For July 1, -June 30;-19. .ak t -tea f <br /> Type Construction Disposal Site_... <br /> No. of Units Equipment Storage/Cleaning Location(s)a ' t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ` <br /> Operator Name 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. <br /> HameownefOrlir_ensedmeent'e signature aer'ifwzthe fattovvlri5:1rprti y+t1?tin,theperfcrmanceoftlidworkforirihichthispermitisissued,lshallmotemplo�n:y�ersrr <br /> in such manner as to become sutrject to workman's c'oaipensat;o; }arrs r'i:al=:;;1! ;" <br /> Contractors hiring or sub-cont.makipp cer ifki 8 +i;e s iicvv:ng; 'i Cettifyllhat it the performance cf the vrork forwhich this parmit is issued, shad <br /> employ persons subject toworkman's compa,ssatiutj laws of Cs'ifc ; + <br /> I hereby certify that I have prepare this a plication and that the work will be done in accordance with San Joaquin County h�f <br /> ordinances, state laws, and rules re tions of the SavKJoaquin Local Health District. { I + <br /> APPLICANT'S SIGNATURE X t <br /> _ FOR DEPARTMENT USE ONLY <br /> , r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> ` f DATE DATE REMITTED. AMOUNT ' <br /> FEEgs'fit' _ r <br /> LESS Wk I <br /> r} V <br /> PRORATION <br /> PLUS f <br /> PENALTY li <br /> OTHER <br /> . r <br /> OTHER - <br /> Received by Date ,Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> 'APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 p <br />