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I' it Will Be Processed When SubmitteOPropers,amprc.o.+• - <br /> - �O 5D APPLICATION <br /> ct✓( <br /> '(For Non-Transferable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PER � — —z— <br /> LIQUID WASTE <br /> Alipl ication is hereby made to carry on business in the jurisdictional area of the San,Joaquin•Local Health District _ <br /> rn Business Name (DBA) � Address��� �• d G> E /Y_T <br /> }�,�a,, �( ��pp- <br /> aOwner G ddress.:. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness,Telephane No. Emergency Telephone Na. <br /> -j Contractor Licence No. <br /> Applicants Name {Print) d Title = Dates <br /> Please check Applicable Category(14)and Fill in the Required Information 3 ; ,`.-"� `• ' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> - <br /> For July 1, -- _June 30, 19 -- � -Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Mea§}fres No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1; — June 30, 19 <br /> No. of Vehicles Stored r- <br /> No. of Chemical Toilets Stored <br /> 3. IN PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E..Nae <br /> jD �' �DU C.C!!�3 Test Date/Time �P -���•���8� �QO Aim. <br /> Test Location Z - <br /> 4.- ❑ SANITATION PERMIT <br /> Job Address/Location s <br /> Owner Address <br /> El SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> _ ❑ PERMANENT 13TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction r* Disposal Site <br /> No. of Units — _ Equipment Storage/Cleaning.Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> s <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY for July 1, -June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> HomeovimerorUc*h ed agent'sslgfwli receet#lestttatotloway."I certify thatintheperformanceof the work for which this permit iMssued,fshall.notempioyanyperson <br /> t Irl such mantter as to become bR,�I W to wotkrriall s compensation laws of Cafilorni(': ; .. "; <br /> Contractor's h; of s�contmcting signature-certifies the fallowing. t Certify that it!the performance of the work for which this permit is issued.I shall <br /> employ parsons Iwbfect to workman's compensatiaa laws of California;• <br /> I hereby certify'tfiat I have prepar this ap cation' d that ock will be done in,accordance with San Joaquin County <br /> I ordinances, state laws, and d regul ns of Sa aq n Local Heal ti-P istrict. <br /> f <br /> APPLICANT'S?SIGNATURE X y - <br /> .FOR DEPARTMENT USE ONLY <br /> By <br /> Fee Is Due. El ANNUALLY ❑ PER UNIT' El PER SITE ❑ EACH' ❑ January 1 &Received By January 31 ❑ July &ReceiwPREMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED. ' <br /> +-DATE 'DATE ,REMITTED AMOUNT <br /> .FEE �,��C) 2r, Y�lrJ1-`G <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - ti <br /> OTHER f. <br /> OTHER <br /> i Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> ! -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SeAVICES -;'l 601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA9520 <br />