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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appllc_tion is herb Irp de t r u i less• the ju is ictio I area of the,.$ap IODQuin- Lpcat�ieal D'I�trict_., \} �t <br /> rn Business Name (DBA) Address `1 <br /> i Owner Address <br /> a <br /> J Firm Partners, Addressesgandipi )n;eN,.�umbers <br /> $ Business Telephone sseEmergency Telephone No.Contractor Licence No. <br /> �,Applicants'Name{Printjy �I : Title ate <br /> -7)and Fill In the Required Information <br /> Please checKAppltcable Category,'(I . <br /> 1.50 PUMPER VEHICLE PERMIT AEGISTRATION (FOR EACH VEHICLE) <br /> Fo�'July 1.' ` "_ June 30;19� t - - - Disposal Sites - <br /> Description(Make/Yr.,Color) <br /> CAL. License No. - CALs License Renewal No. i <br /> Serial No. <<-�r ! ri- - ---..? -Capiacity _ <br /> -Gall-,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 /> 1-13-PERCOLATION,TEST <br /> R.S..Or R.C.E. Name . R.S.or R.C.E.No. <br /> r <br /> I ,--� Test Date/Time <br /> Test Location s t 7 ,/ ._r . <br /> 4. ❑ SANITATION P TI - <br /> f <br /> Job on'Address/Locati _� ..�.-. •. -- t - - <br /> :..� __-�-•--_ ---__�-�- - .�..._� Address <br /> Owner ❑ PACKAGE PLANT i <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY NEW <br /> I <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t ! i <br /> Type Construction <br /> �. Disposal Site 1 <br /> i. Equpment Storage/Cleaning Location(s) � t <br /> No.of Units i + n - <br /> 6. ❑-PACKAGE TREATMENT_PLANT. 'F,or July 1 ^June 30, 19 <br /> Where Certified ' - <br /> Operator'Name y i t jj <br /> Plant Location' <br /> Plant Capacity )-- -'Nd. Units Served <br /> r A <br /> 7. ❑ LAUNDRY For July 1,-June.30, 19 <br /> SIZE: I❑ Less Than 1,000 Sq.-Ft-,t ❑ More Than 1,000 Sq. Ft.T _ .r—N ! <br /> F ❑ DRY CLEANING,Chemicals Used/Amount/Mo.* 1 �t <br /> k Homaownerortkensadagent'ss+ynature oertifiesthefollowing:"Icertify that intheperformance ofthe worktotwhichthisWrilitisissued,IstlallnotemyioYanyperson <br /> in such manner as to become su;m to work+nan's compensation laws Of Calnornia.' �� ,+ • j" ,� } I <br /> s Cotrtrsctof's hi or sub corttrsatlf+g signature eertifas tt>e ng: 1 tollowictntify that In the performance of thi work forwhich this permit is issued,t shall <br /> ( erhptey persons III to workman's compensation taws of California'" � f <br /> r 1f I hereb certify.t tave-prepared t application n ha the-work will be done-in accordance with San Joaquin County <br /> li <br /> tt ordinan es, a laws, les n rl gu ti of a Sa Joaq Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 77/x' 2 rr T _A: r <br /> t <br /> ? FOR DEPARTMENT USE ONLY... <br /> i 'Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Receiv flEMlTd 13 uly 31 <br /> BILLING f REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE;? .DATE REMITTED AMOUNT <br /> t FEE <br /> LESS ► <br /> P_ROAATION.-, �r ,o.•" <br /> PLUS ^',,,,".�".' `�...'„"„�.��.. ''�4---`"'.—• �� ¢�i�.—�� <br /> PENALTY, Y t <br /> �r c <br /> t OTHER � s. — �•�i S i •. _ .".y '} � <br /> j ~r ^� t ` <br /> 2 OTHER AC i ., f .—_L-4.._ `. <br /> 7[ Permit No. Issuance Date Mailed Delivered <br /> p Received by Dat Receipt No. , <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />