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A` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1, APPLICATION f <br /> a <br /> (For Non-Transferable, Revocable,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati s hereby maye to carryon usin s' the' risdictiona!area of th �n J quin Local Health D' #rict .- <br /> H Busin ame (DB ' <br /> Address ; <br /> a Owne Address <br /> L) Firm Partners, Addresses and Telep n umb rs <br /> IcKBusiness Telephone No. Emergency Telephone No. ! <br /> 1 Contractor Licence No. 'Z ` <br /> i <br /> L Applicants Name(Print) Title <br /> Date <br /> Please check#Applicable Ca gory(1-7)and Fill in t e Required,Information ` <br /> 1. 0 PUMPER,VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .w June'30,'19 Disposal Sites € <br /> Des&iption{(Make/Yr.,C_olor)*r I <br /> Serial No. CAL. License No. CAL. License Renewal No. ; <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address } ! <br /> 2. ❑ PUMPER YARD }" <br /> 4 <br /> For July 1, June 30, 19 _ , <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. 0 PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lo��Ion Test Date/Time - <br /> 4. O SANITATION PERMIT ' <br /> Job Addre Locati n 2 <br /> Owner Address. Q/ t <br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT - LI <br /> 9KPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER W <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction i <br /> Disposal Site " <br /> No. of Units Equipment Storage/.Meaning Location(s) r p <br /> 6. ❑ PACKAGE TREATMENT PLANT For"July 1, -June 0, 19 i <br /> Operator Name I Where Certified !1 <br /> Plant Location <br /> Plant Capacity No. Units Served u� <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i : ' •+ I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000.Sq. Ft. > ' <br /> i' <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> HortteMWngrorlibencedegent'Rsi natureeArtifiestt+et'oppyri ithat � ''"�-• r <br /> g naWsofCajfaiirttheperfor�ltanceaftfle.nrorkferwhichthlsgerm;tisissuea is#�allnoter ployanyperson <br /> in such manner as to trecOrpQ S11biect to workman's compensation laws of Ca itti int <br /> e MhHHMols hiring or suis-Gohtrscting 099nature certifies t?14, 'uila�,nri: '.f i eflif•°tha.in the perform L,•pr•K fAr which t;tiS^ar j ' <br /> employ persons Subject to wars marts ccmyensatiolr ,s Int Cali;c�iliu. 4 ` � ' p i mitis issued.!shall <br /> I hereby certify that'l have prepared this application and that'the work will be?done i a cordanc.ewig h San'-Joaquin'County <br /> ordinances, state laws, an rules and re lation of the San Joaquin Local'eHealth District. <br /> APPLICANT'S SIGNATURE X ) 4 , <br /> S f <br /> FOR DEPARTMENT USE ONLY' s 1 <br /> r� F <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Ry January 31 <br /> y El July 1 &'Received By July 31 <br /> t BILLING REMITTANCE r REMIT <br /> _ BASE EXPLANATION $ -y �'' 1AMOUNTDUE CHECKED <br /> >! DATE - .DATE I .REMITTED :. t AMOUNT <br /> FEE �,,�,,... <br /> LESS 1 # } r i <br /> PRORATION -�. ! i �} <br /> PLUS f [ <br /> PENALTY - ' <br /> .OTHER <br /> OTHER <br /> Received py Date Receipt No. Permit No. - Issuance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />