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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 /> Applications hereby mad to carry on business'n the jurisdictional area of the ''an Joaquin Local Health District <br /> Business Name (DBA) sL/. /' ! /909 RZ T& �sf��✓ Address � � D� �� �ys� sT1�/� <br /> z Owner Address . <br /> K <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. y66 ,"9'6 O 7 Emergency Telephone No. <br /> Contractor Licence No. ZJ�a'S 7 <br /> Applicants Name (Print) Title �S'�• Dale <br /> Please check Applicable Category (1-7)and Fill in the dequired 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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT <br /> Job Address/Location <br /> Owner_Jr xlf- 02=1 Address -- <br /> Vf SEPTIC TANK ❑ CESSPOOL LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> 99 PERMANENT ❑ TEMPORARY Ild 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 /> Homaowner orlicensed agent's signature cer!ifipsthn following :1 C9rtify)lh;vt in the nerfntmanreof the work Iot which this permit Is issued.I shall not employ any person <br /> in such manner as to beconm alblect to workman so' n58tin; I:nIx of Cafib,::.:,a <br /> Contractor's hiring or sub-contra^titio signotura eertifias :he nohow Ino. i rertily that In the perforrnanc*of the work for which this permit Is issued,i shall <br /> employ persolz subject to workman's ccmpensation laws of California." <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 regulations a San Joa 'n Local Health District, <br /> APPLICANT'S SIGNATURE X - Z <br /> �L( <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION (17 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM IT/SERVTErzs 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />