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. . <br /> Applications Will Be Processed When Submitted Properly Completed. BeSureTosign <br /> APPLICATION <br /> r (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONME'N AL HEALTH PERMIT <br /> LIQUID WASTE <br /> ` Applicakioq�s h reby m e to car on business i he lurri�sdickional area of the oalin Lol_.He D <br /> Business Name (DBA) 1L�Q`—'—Address_C[ fG� Jl� <br /> r Address <br /> a Owner—L--. <br /> Firm Partners, Addresses an Telephone Numbers y <br /> IL Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. pate <br /> Applicants Name (Print) Title _ 1 <br /> Please check Applicable Category'0-7) and Fill In the Required Information 031 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -:- _ <br /> For July'1, <br /> '-` June 30j-19 =Disposal Sites - - <br /> Description(Make/Yr., Color) <br /> CAL. License Renewal No. <br /> Serial No. <br /> CAL. License No. s <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 /> _ J <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST } k <br /> R.-S.or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> � Test Date/Time <br /> Test Location I <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ' <br /> Owner j Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL' ❑ LEACHING FIELD ❑ SEEPAGE PIT 0.-PACKAGE PLANT V t: <br /> ❑ PERMANENT 13 TEMPORARY' ❑ NEW El REPAIR OTHER 4 <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 V' <br /> Type Construction.. - Disposal Site <br /> No. of Units Equipment Storage/Gleaning:Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> -7. ❑ LAUNDRY : For July 1, -June 30, 19 r ire <br /> SIZE: ElLess Than 1,000 Sq. Ft., 13More Than 1,000 Sq. Ft. ox <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> il�rrreov+me�e•Ite0nsWAgnnt'.•,. "art:e�sex•r#O-sthRfollowing:1c�rfifytoitlitthelierf"anceofthe work iorwhiChthlsperm;?isissued,fshaltnotimpl(lyzrtyodr;Cn: <br /> s in such mannr.as to beCl mr..affil's to workatans Cgrnpensation laws(f ratifcr; - <br /> Crnmector'a hirir►g ar sA)'.0o Afta ng sigmtFire cAr�ls the followings "I certify that in theperformance of tflt:work for whisfl Ws permit is issued,I sheik - <br /> Bmploy persons subject to workman's compensation Paws of California: <br /> I hereby certify that I"have prepared this application and that the work will be done in accordance with"San Joaquin County ". <br /> ordinances,state laws, and rubs and r ula' ns f he San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X F " <br /> I FOR DEPARTMENT ONLY <br /> - 1 &+Received 8Y(January 31 ❑ July 1 &Received By July,31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAG January REMIT <br /> F BASE EXPLANATION HDAT R I 4NG AMOUNT DUE CHECKED <br /> DAT 7Ul p�(.t REMITTED AMOUNT <br /> FEE /O <br /> LESS <br /> PRORATION <br /> 3 PLUS _ <br /> - PENALTY <br /> OTHER <br /> t OTHER h. - <br /> i _ - Issuance Date_ - Mailed Delivered, # <br /> Received.4y - Date ,Receipt No, Perm�1 No.. <br /> _ 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES <br /> I <br />