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APPLICATION <br /> or Non-Transferable,Revocable,and Suspenda' SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT" <br /> LIQUID WASTE <br /> Application P.3rpereby made to caron business in the jurisdictional area oft San aqui&Local Health Di�stict v <br /> Business Name (DBA)� I�Qts Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Teleph n Numb <br /> E Business Telephone No. -" d� w_ Emergency Telephone No. <br /> Contractor Licence No. t <br /> L Applicants Name (Print) I zrfl 0. Title pate <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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 &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 ocation Test Date/Time <br /> 4. SANITATION PERMIT f <br /> Job Acid r s/Location b d o <br /> Owner t r Address f�/v w Z- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR A OTHER DgAI 1U } �D <br /> 5. ❑ CHEMfCAL TOILETS For July 1, -June 30, 19 /// O, <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 <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 /> Homeowner or licensed&gent's signaturecertifiesthe following:"I certify that in the performance of the work IorwY6h this permit is issued,f shallnot employ any perse <br /> in such manner as to becorne subject to workman's conrMsation laws otCaliforttle" <br /> Contractor's hirirm or sub-contracting signatures certifies thr fryRowinrg: A certit'y that In the partcrntance of the work for t+bich t`t'rs permit Is issued,I shall <br /> eroplay persons subject to workman's cornpensatien laces of Cai lomia-- <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 rules and gulatio f the San Joaquin Local Health District. <br /> r <br /> APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due- ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING, REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 14 I S <br /> r� <br /> LESS <br /> PRORATION <br /> PLUS a4 { <br /> PENALTY l' <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuanice Date Mailed Deliv <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 IE.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />