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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAPPllcauon <br /> APPLICATION <br /> ..� (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ' is here�ry ma Marry on usine' i he,jur' dictional area of,thep} Joaq n Local Health Distric zzl�` <br /> rn Busine ame (DBA Address _s7 <br /> r� , <br /> z Own �M Address <br /> a <br /> Firm Partners, Addresses grid e phone bers <br /> a Business Telephone N -ll�1f' e U Emergency Telephpne No <br /> q.� <br /> Contractor Licence No. �- F - <br /> ' Title Dat <br /> Applicants Name (Pint)} a` <br /> : * <br /> Please checkk Ap.o <br /> plicable t ory(1 7)and.Fill in the R red Information t wt h c 1 <br /> 1. O,P.UMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July__., ne 30,:,19-- -. Disposal-Sites — <br /> Description(Make[Yr.,Color]- . <br /> Serial No. <br /> ' t <br /> C . License No. CAL. License Renewal No. <br /> Capacity � T � •� Gal:,Weights & Measures No. } <br /> Equipment Parking�Add ress <br /> 2.NL PLUMPER YARD�t` <br /> f <br /> For July 1, ' 1June 30, 9 <br /> :. <br /> "r No-,of.Vehicles Stored <br /> No;;of_,Chemical Toilets Stored f <br /> 3.- ❑ PERCOLATION TEST fi <br /> R.S. or R.C.E. Name R:S. or R.C.E. No. <br /> i <br /> TestLLtion Test Date/Time I <br /> ! F 1 <br /> a. El SANITATION PERMIT s. i <br /> / r; <br /> Job Address/L ation . <br /> Ow r Address s <br /> IPTIC TANK 11 CESSPOOL ❑•LEACHING FIELD EE PAGE P ❑..PACK GE PLANT <br /> L� PERMANENT © TEMPORARY ❑ NEW L REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 j <br /> Type Construction Disposal Site <br /> t � <br /> No. of Units '�Egiaipment Storage/Cleaning Location(s) i <br /> f � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> Operator Name ;F '•"" ` # i <br /> Plant Location _ '— <br /> No. Units Served <br /> Plant Capacity <br /> I <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 - -- , <br /> SIZE: El Than 1,000 Sq. Ft.,, ❑ More Than 1,000 Sq. Ft. <br /> . ;r <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. I ersnn <br /> Hpmeownerorlicensed ngee+Yssignature cerHfiesth )ion!i�tg: i tlfythatlntheperformanceof'theworktorvfiichlhispernti Isissued,lshailnotempioy8 yp <br /> in such manner as to became subject to,vorkma;r>comperisatioii law::of Galrturit:z ' '�y vj <br /> v <br /> Contractor's hiring or sub•crintrActing signatum cgrffl�s nt t toN`6wing: I certify,that in the performance ct tht wank tar which this permit is issued.I hall <br /> employ persons subject to wcrkmal,s ccmpensalim,laws;cf Caliturnia. i ' <br /> ` I hereby certify that I have prepared this application and that the work will be-done-in-accordance-with San Joaquin Coun� _ <br /> ordinances, state laws, and rule nd regulations�of the San Joaquin Local Health District. {/ <br /> . _ J <br /> ,i <br /> APPLICANT'S SIGNATURE X <br /> w FOR DEPARTMENTUSE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 B:.Received BylJanuary 31 ❑ July 1 &Received By July_3# <br /> ,. REMIT <br /> BILLING REMITTANCES AMOUNT DUE CHECKED, <br /> t y DATE -bATE REMITTED,, AMOUNT <br /> BASE EXPLANATION <br /> FEE 14l S r P1 <br /> LESS T <br /> PRORATION <br /> PLUS <br /> .t 1. I <br /> t. OTHER <br /> V Sok E•e t ♦ `' 's —s <br /> OTHER <br /> ' Received byDate Receipt No, Permit No. lssu rice Date W� Maiied�Y Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />