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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> .(For Nan-Transferable, Revocable,and Suspendable) SEpTAGE _ <br /> ENVIRONMENTAL HEALTH PERMIT ` <br /> C, "' LIQUID WASTE ;. <br /> Application is hjWiPby made to car b nes in the jurisdictional area of the SapJoaquin Local He8a ; <br /> ,n Business Name A} Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numb rs <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Date�. <br /> r L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required information 3 ± <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 41, Disposal Sites - <br /> Description(Make/Yr., Color) I " ...9 <br /> Serial No. -1 CAL. License No. CAL. License Renewal No. <br /> 'f <br /> Capacity Gal.,Weights & Measures No. ; <br /> I Equipment Parking Address .r ' l <br /> f 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> ! 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. - <br /> i Te t Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location A. f� ! <br /> Owner Address <br /> DSEPTIC TANK ❑ CESSPOOL +.LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> r ❑ PERMANENT ❑ TEMPORARY s ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,' June 30, 19 <br /> Type Construction - Disposal SiteNo. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT FFor July 1, -June 30, 19" F h <br /> Operator Name t - Where Certified " <br /> Plant Location <br /> ) No. Units Served " ! <br /> Plant Capacity 9 <br /> 7. ❑ LAUNDRY 'For July 1,-June 30,09 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmOUnt/MO. <br /> rf li±•r �r:'1!!hoc.CTf�fllaRC4,Lfwn!';e-�`:or':;!i'+chth!spermit isissueds,ishall not empioyany persf . <br /> Home owner orlice:sodagent's SSgnvttlre� <br /> manner as to bccomo sub;.a.S to to,Isl "� <br /> at; <br /> Contractor's hiring or salt-canYr;�_:'srs.=:r,��rz.s::' ':�''.'" _ .•. .. - •?!:1:.•-•,�:ik�-a=°i i��;`i;':., I�a�.aork far tilhich this permit is issued,I shall <br /> in such ma <br /> employ persons subject to workrilan's corjpu7satiu:i id s5 v.�ai;,:.:,:a. �' <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 es and r mations the San Joaquin Local Health District <br /> APPLICANT'S SIGNATURE X <br /> Y —Z--3cCsr� A? i' <br /> Z <br /> DEPARTMENT USE ONLY r� <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE <br /> L. <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> s DATE t DATE REMITTED - AMOUNT <br /> FEE <br /> LESS r <br /> PRORATION <br /> i PLUS <br /> PENALTY 7 � '-O /V <br /> OTHER T !: <br /> OTHER <br /> -3_ <br /> Received by Date Receipt No. Permit No. issua4ce Date V Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:'r ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i". <br />