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_77 <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAppllcauon. } <br /> APPLICATION <br /> (For Non-Transferable,Relrocable,-and Suspendable) SEPTAGE !' <br /> I <br /> ENVIRONMENTAL HEALTH PERMIT" LIQUID WASTE. <br /> Application is h re y ade to carry on business in the jurisdictional area of the San Joaquin Local Health District j <br /> F Business Na a (DBA) <br /> Address -- <br /> z Owner : i Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No.. o"l <br /> a•Bttsirress Telephone No. - <br /> Contractor Licence No. lea <br /> tI� <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July June 30, 19 - Disposal Sites <br /> Description(Ma Color) <br /> CAL. License No. . License Renewal No. <br /> Serial Na. <br /> Capacity I., 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 Stor <br /> 3. ❑ PERCOLAT EST <br /> R.S. or R.C.E. <br /> R.S. or R.0 . ame No. <br /> T ovation Test Date/Time <br /> .4. SANITATION PERMIT <br /> Job Address/ ovation 4 3W ti� e <br /> Owner Address itil <br /> ❑ SEPTIC TANK 13 CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT( I rte^+ X/ ) � <br /> . PERMANENT 13 TEMPORARY NEW <br /> 1:1 �{ <br /> REPAIR ❑ OTHER `�'� � 81-A <br /> JbiCHEMICAL TOILETS For July 1,-June 30, 19 <br /> i Type Con ion a % Disposal Site . <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> . <br /> 6, :❑ PACKAGE TREATMENT �For'Juky 1, 'June 367'i9.- 1 � <br /> . , <br /> Where Certified I <br />' Operatbr,,Name <br /> a Plant Location ' € <br /> -Plant Capacity - - o Served <br /> 7. ❑ LAUNDRY For July 1,.J .v- ,....�, # <br /> t SIZE: ❑ Less 0 Sq. Ft., ❑ More Than 1,000 Sq ,Ft: <br /> E ❑ ANING,Chemicals Used/Am ourit/Mo. """" " '� "" •$issued.Ishaftnotemployanyperson <br /> I <br /> $ t "ICEItIhtRatiatlte.perinrnlamootthewarkforwhictitbisp - <br />° Homeawnet-orlicbnwdagatwssi9natureeMttflesthetoHrtwi�rrg aa1k1 ~ <br /> in such manner as to become Soject to workman's compamation taws of C f8rltla. i r <br /> (•p11tFeCtor'S tsiriri$,or $uh:Cfir'•trr�ciin .signatuio certifies the fntlawki�it�1 ;ty tRat ITn9fe perfatmance a1 the work for which this permit is issued,i shall . <br /> empiay pefsolls subject to YJorklnan's compensatlOrl`laws Of Cali'MITI-11" <br /> I hereby`certify that l have prep a his application and that the-work will b done in accordance with San Joaquin County <br /> ordinances, state laws, a re ula s ft oval H th District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑�PER..SITE EACH January 1 8 Received 43y January 31 ❑ July 1 &Receiv REMIT <br /> d By uIy 31 <br /> ' BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE _ .,DATE. REMITTED AMOUNT <br /> r <br /> 0' <br /> FEE <br /> LESS v <br /> PRORATIONPLUS <br /> 1 <br /> L <br /> PENALTY <br /> OTHER <br /> OTHER y <br /> Re eived 6y 4 ate n r„. F Receipt No' Permit No. Issuan a Da a Mailed Delivered <br /> t <br /> APPLICANT—RETURN'ALL COPIES TO: "ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL AYE.,P.O.Box 2009 STOCKTON,CA 9955201 <br />