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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> Q. ENVIRONMENTAL HEALTH PERMIT <br /> 01 LIQUID WASTE <br /> Applicationj�hergby maAto carry on business in the jurisdictional area of then Joaquin Local Health District J <br /> y Business Name (DBA)_ <br /> {f -S Address d'�/3-� / <br /> z Owner w- .T Address _ .. <br /> LJ Firm Partners, Addresses and ele hone Numbers <br /> $ Business Telephone No. a Emergency Telephone No.. <br /> Contractor Licence No. <br /> 4 — Z Title Date- <br /> dX Applicants Name (Print) } <br /> Please check Applicable Category (1-7)-,and Fill In the Required Inform tion. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites <br /> For July 1,___.June 30, 19 �- - Dis P <br /> Description(Make/Yr., Color) <br /> CAL. License No., CAL. License-Renewal No. <br /> Serial No. <br /> Capacity 'Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 y <br /> No. of Vehicles Stored <br /> .No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C,E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. .❑ SANITATION PERMIT _ <br /> Job Address/Location O � ~ <br /> Owner V, ��'� v Address <br /> 11SEPTIC TANK 11CESSPOOL 'LEACHING FIELD SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IN REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> F Operator Name r <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 W <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,, ❑ More Than 1,000 Sq. Ft. t, <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home owner orftcensedagent's st r.P!ttrer. rtl +� tl •'r:>".e�;'I^^ '9cetj'vth^t inti;eporfcrmanceoltheworkIorwhichthispermitisissued,Ishallnotemployanyperson <br /> n such manner as to become Su' _, YJGIISlil2i? GBif;E^il�afitr[c i21 OiE cs; ri11a." <br /> -- Contractor's hiring or sub consr�c'..t� i nature r.SrFS a:,t:;3' tri, irg: "1 tertily that in tate performance of the work for which this permit is issued,I shall <br /> employ persons subject to work non s compe-9a a It laers of Califoin a:' -r` t <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws,and rule a ulaWl f the San gLin Local al D' rict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY. <br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 REMIT <br /> ' BASE EXPLANATION BILLING REMITTANCE `s AMOUNT DUE CHECKED <br /> DATE- DATE REMITTED AMOUNT <br /> FEE, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHERor <br /> OTHER <br /> Received by Date Receipt No. Permit No.-' Issu ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 ff <br />