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Applications Will Be Processed When Submitted Properly Completed. Be SureTo51gn 1newppucalivn <br /> APPLICATION <br /> �f (For Non-Transferabte;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> 0 ' [ LIQUID WASTE _ <br /> Applicati i ereby.�made to car n usiness in the juris ictional area of the San Joaqui Loc Dist is CT�� <br /> w Business Name (DBA) <br /> "Om <br /> Business <br /> Address J rya? <br /> aOwner I :, -,. -_, Address , <br /> Firm Partners, Addresses an elephone Numbers ' <br /> 77- <br /> Q. Business Telephone No. — S7- 6 - Emergency Telephone No. <br /> Contractor Licence No. L�Lsr te <br /> f� <br /> D <br /> a Title a <br /> Applicants Name (Print) <br /> Please check Applicable Category(11-7)and Fill in the Required Information t;I x .$ r r, l ,. ...R <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. !M CAL. License No. CAL. License Renewal No. <br /> Capacity '11-Gal.,Weights & Measures No. <br /> I� <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 <br /> 3. PERCOLATION TEST I 1p \ <br /> R.S. or R.C.E. N e R1VMAi_t) EL E711 R.S.or R.C.E. No. G� <br /> 011 <br /> Test Location M �TI) Test Date/Time <br /> 4.- ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner IM Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT 11TEMPORARY ❑,NEW ❑ REPAIR ❑ OTHER <br /> 5- ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ <br /> Type Construction Disposal Site f <br /> No. of Units li Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name P 1 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> i <br /> Home owner or licensed agent's signature certifies thefollowing:"I certify that in.the.performance of th a work f or:^rhirh this perrtsif is issu et);I shag not employ any person <br /> in such manner as to become subject to workman's compensation IaNS of CaliforrVi0 i <br /> Contiactor's hiring or sub-contracting d gnature certifies the foilowiag. 41 certify that in The performance of the work for which this permit is issued,I shall <br /> employ opilifticn 15n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,land rule a regulations of the•Sap Joaqui Local Health District.` <br /> I�. <br /> APPLICANT'S SIGNATURE X <br /> _ 'ilLf FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY II ❑ PER UNIT, ❑ PER SITE ❑ EACH' ❑ January 1 &Received By Januat316EedJuly 31T <br /> BILLING REMITTANCE $ ED <br /> BASE EXPLANATION DATE - DATE REMITTEDNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS I� <br /> PENALTY'' <br /> rI i <br /> 4 OTHER f, <br /> - '. - <br /> OTHER <br /> Ct �Cp O <br /> Received by Date Receipt No. - Permit Na. lsS: cc Da Maned Delivered <br /> APPLICANT' RETURN ALL COIIPIES TO:``�ENVIRONMENTAL HEALTH PERMIT/SERVICES` 1601 E.HAZ AVE.,P.O.Boz 2049 STOCKTON,CA'95201� <br />