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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Traneterabie,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hergby ma c b sine�ss in the unsdictional area of the S n o al al �irir� t 1 <br /> Business ame (DBA) <br /> L --J- Address 1 <br /> Owner <br /> Firm Partners,Addresses and Tel ne uhbew� - ---- - <br /> $ Business Telephone No. Emergency Telephone No. ---- <br /> Contractor Licence No. _ - ---_. <br /> Applicants Name (Print) I--- Title <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> CAL. License No. CAL.License Renewal <br /> Serial 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 Location _ Test DatefTime <br /> 4. ❑ SANITATION PE2M 2 <br /> Job Addr s Locati� (� " <br /> Owneri rLEACHING <br /> Address❑ SEPTIC TANK ❑ CESSPOOL FIELD �❑ EEPAGE PIT -❑ PACKAGE PLANT <br /> 1:1PERMANENT Z1TEMPORARY REPAIR ❑ OTHER <br /> - ❑ CHEMICAL TOILETS For July 1, -June 30, 19-- <br /> pe Construction __ Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ------ -- - _---- <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1, - June 30. 19 S <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. T-____--- / <br /> Non+s owner or t3eenaedag�nt'c Sigtutttre rrlitilbsthelo4lowirtg:A Certify that IA tote pertcrniance of the wcrkfor which this permit is issued,I shall riot employ any person <br /> in such manaer'.s to became subject to workwm's campeasatiG-.i lags of C21iforraa <br /> Contsaetol's hiratA or sub-ec,.r2sace;np signat aamhar !ire !f*0+ine- "'{ ertify ihni ht the i>Frtarinance of the work for which thls permtt Is issued;I shad <br /> entptoy persoos subject to workman's corttpematiort taws <br /> ~1!hereby certify a ve�repd this plication an at the work will be done in accordance with San Joaquin County <br /> ordinances,'s 5, d regula ions th Sri Joaqu Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due-.❑ ANNUALLY ❑.PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received Py Jan,�ary 31 ❑ Jury t &Rece,ved By July 31 <br /> REM IT <br /> BASE EXPLANATION 1 BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> DATE DAT REMITTED AMOUNT <br /> FEE Its <br /> LESS <br /> PRORATION ......._` <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dat Receipt o. Permit No. Issuance to Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON Bort 2009 STOCKTON,CA 96201 <br /> .,P.O. <br />