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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �+t (For Non-Transferable;'R@YOCoble, and Suspendable) r SEPTAGE ' <br /> ENVIRONMENTAL HEALTH,PERMIT 1 <br /> LIQUID WASTE <br /> Application ereby made to carpj an business in the jurisdictional area of th an ippiquin Local Health District <br /> ,�Business Name (DBA) ) � �- Address �O �'SJ�Il <br /> aOwner Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. V666 Emergency Telephone No. ; <br /> Contractor Licence No. � r <br /> LApplicants Name (Print) J. Title,= M Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information w c <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites : n <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 <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. �i SANITATION PERMIT <br /> Job Add r ss/Location <br /> Owner ��t N� Address sryU' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD .SEEPAGE PIT ❑ PACKAGE PLANT a <br /> 10 PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER i <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 a rd <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 a F r <br /> A SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, - <br /> HomeewnerorlPconsedagent"ssi naturecartif is he following,-"r certify Mal,iltheperfarmanCe+3ftht:Work forwhfiehthispermitisimed,Ishall notemployany persnn <br /> In such manner a$to became subject to wurl Mati s cottl1*%at1on laws of Cal;;tor nia.`' <br /> Contractors hiring or sats.e©nttacting signature certifies the fotfawing_ "I certity that in the plxformallee at the work for which this permit Is issued,I shall <br /> employ persons subject to workman's compensation taws of Czlit+3Faia:' <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 ruJes and regul 'ons oft an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Recelved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -G � <br /> LESS ° <br /> PRORATION <br /> PLUS, <br /> PENALTY 1 <br /> OTHER �f <br /> OTHER <br /> Received by - Date Receipt No� Permit No [Issuancitt Datd y Mailed 'Delivered <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 - <br /> Y <br />