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Applications Will,Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> 3 � APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �— <br /> LIQUID WASTE <br /> Application is hereby mad to carry ora bu iness a juri ctional area of the�Joaqu n Local al D'strict + <br /> ,�Business Name {DBA) �� Address <br /> aOwner I Address <br /> Firm Partners, Addresses a T I hon tubers <br /> CL <br /> Business Telephone No. Emergency Telephone No._. .._ <br /> Contractor Licence No. <br /> L Applicants•-Name (Print).- Y Title <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> ,11 -0-PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />—For July 1 c June 30,.1,g Disposal Sites - w <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.:License Renewal No. <br /> Capacity Gal.;Weights & Measures - <br /> Equipment Parking Address I <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 , ,� I . } w a <br /> R.S. or R.C.E, Name R.S. or R.C.E.No. <br /> Test Location I Test Date/Time ) <br /> 4. ❑ SANITATION PER <br /> Job Address/Locatio i <br /> Owner — Address " �' i <br /> ❑ SEPTIC TANK ❑ CESSOIO0L C1 LEACHING FIELD SEEPAGE PIT' ❑ PACKAGE PLANT <br /> 1:1 PERMANENT ❑ TEMPORARY ❑ NEW S REPAIR "` :- . ❑ OTHER <br /> All <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 k <br /> Type Construction Disposal-Site[ t <br /> No. of Units ; Equipment Storage/Cleaning Location(s) ► I <br /> F. 1:1 PACKAGE TREATMENT PLANT For July 1, -June 30,'19 <br /> Operator Name <br /> r; � tjt � Where Certified <br /> Plant Location ' <br /> Plant Capacity r No. Units Serve <br /> d�� <br /> 7. ❑ LAUNDRY For July-1,-June 30; 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq!Ft. I t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ) I <br /> Horns owner neraicancedage, t ectlsign <br /> orurnrerx;fie5the#Aljawirtg:"]certify hatlntheA-rformanceafthewerkforwl� hiSpermitisisSued.Ishallnvtempoyanypersan t <br /> in such manner as to become subject to��rrk�ar;'s cam enation fak'M of Call.ssrri� ! <br /> empConlra per's tliritbi o, su4=con1rnr14nLa si,,,rt,j;c. ,;y,�;e� .t,� fattow.n;:u,-. certify that in the performance a1 the work for which this permit'is issued,1 shall <br /> employ persons su bjees to v mr,3tj's JIYir 4G �! iiiiurli7�. <br /> I hereby certi y i have prep ed this ap lication and that the vV23Fk"Will`b `done in accordance with San Joaquin County <br /> ordinances, state laws, n ule a d u at o s of the San Joaquin Local Health District. } -v I <br /> APPLICANT'S SIGNATU r ' ` <br /> FOR DEPARTMENT USE ONLY y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT[)UE CHECKED <br /> - -DATE DATE REMITTED T. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION •� _ / ( .� <br /> PLUS I <br /> PENALTY <br /> OTHER fF <br /> OTHER <br /> • Receive by` Date - - Receipt No-: �"�?' of i o Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER SERVICES �!160i'E:•HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />