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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 /> C� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is r to on b the jurisdictional area of the Sa Joagw. Loca alth District <br /> yBusiness Name (DBA) ddress <br /> a Owner C Address IASC 457 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - C� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 'ler' Date <br /> Please check Applicable Category(1-7)and Ril in the Required"Information a <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 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 a <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4.0SANITATION PERMITL���, <br /> Job Address/Location [[ <br /> Ow//ner ''��+-� �E}��'�l� Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ]SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY fi<NEW ❑ REPAIR 0 OTHER <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 i <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 /> Home owner or licensed agent's signature certifies the following.1 Certifv tb it in tho perform ince of the wnrk for Which this permit is issued,I shan ricags4ftyully <br /> In such manner as to become subject to workman's compensation laws of California * <br /> Contractor's hiring or sub-contracting signature certifies the following: 'I cerlilythat in the performance of the work for which this permit is asseef,t <br /> employ persons subject to workman's compensation laws of California." r" <br /> I hereby certify that I have prepared this applic and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules a gu s o he San Joaquin cal Ith District: <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DAT REMITTED Y AMOUNT DUE CHECKED <br /> AMOUNT. <br /> FEE 't(1 <br /> LESS r�C <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER �. <br /> J ' <br /> Received by Date Receipt No. Permit No. Issuanci net Mailed _,Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />