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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 41 <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon bus.ine In the jur sc4ctiona.1 area of the-an Joa uin Lo"I He th District <br /> _w <br /> Business Name (DBA) <br /> ) <br /> a Owner C. i i i L kX -- Address <br /> Firm Partners, Addresses ard Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) .-Title i 4 t� `-- Title Date <br /> - <br /> 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 J <br /> Description(Make/Yr., Color) <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 /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored (f� <br /> 3. ❑ PERCOLATION TEST j <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location C, Tat /T re <br /> 4. 1:1 SANITATION PER IT • ✓5-� �� <br /> Job Address/Location t'+ ► _L) _.1_.A,i <br /> Owner Address <br /> SEPTIC TANK ❑9C•ESSPOOL EACHING FIELD EPAGE PIT Q PACKAGE PLANT <br /> PERMANENT 0 TEMPORARY W '❑ REPAIR OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <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 /> Homeowner or licensed agent's sigr ror rertif, 5e±fe'+ownS Icet ylth wok kfcr.^chichthispermit sissued.ishailnotemployanyperson <br /> in such manner as to become subioct trlI., ' <br /> atf,o,n:a <br /> Contractor's hiring or s ab cattteacttn* , rtsr> rh t:Ioavin_: "i terrify I+nl.n the performance of the work for +hich this p+^rntlt is icstle'i;t shall <br /> employ persons subject to ,ani.,of Ca'sfa;.l r,. <br /> r-- <br /> I hereby certify th have prepared ttWs application And that the work will be done in accordance with San Joaquin County <br /> ordinances state laws, rules an t 9 San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <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 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> }�► DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -Received by D to I Receipt No. "` Permit No. Issuance Date Efled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., .0.Box 2009 STOCKTON,CA 95201 <br />