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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 4,- -35 <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name DBA) l'=F�iE' �ll� l�i�7�C�i��L Address /a7� l�jd�C 440 <br /> i Owner oac[l/V Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No, Q J 3 Emergency Telephone No. <br /> a <br /> Contractor Licence No. ,t! p <br /> a Applicants Name (Print) Title «� Date <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 <br /> heroical Toilets Stored <br /> 3. RCOLATIO <br /> R. r RN T.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time 7 -- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location /,'✓ ! <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30. 19 __ <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 /> Homs owner or licensed egens's•in"tureest+t`leathofollowing:"I rerti`y that In Me pet fo.mance of the workfor,xhich this permit is issued.I sha!l not employ any persc <br /> in such manner a,to bee:me subjec!io Korks;ar P moeesatioo'aws of Catifirl sta <br /> Contractor a hiring nr ,P,b-cnntraCtjng stprwturr cerwills the roHowlrlJ: l certify t'zit in the petforlsame of the work for which this permit is issued,f shall <br /> employ persons sublact to%;:orkmari s compe"iotl laws of Cafifornia." <br /> I hereby certify that I have prepared this applic o ethe work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and Ie and regul 'o o quin Local Health District. <br /> APPLICANT'S SIGNATURE X -- <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 /> Q / p AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> HER <br /> eived by Date Receipt No. / Permit No. Issuance Date Mailed Delivered <br /> PPLICA —RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />