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Applications Will Be Processed When Submitted Properly Completed. Be Sur ITo Sign The Application. /oil <br /> 9 f <br /> APPLICATION' <br /> 1 Von-Transferable, Revocable,and Suspendabl . SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE <br /> Application is her y made to carry on business in the jurisdictional area of the SS-an Joa�,uin local Health District <br /> A Business Name (DBA) 2 '4e Address_! _C <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 'n Business Telephone No. / h 1 Emergency Telephone No. <br /> �Contractor Licence No. ��,�rsa:2 <br /> � <br /> Applicants Name(Print)_�,J r z.e f—g . Title _i.br Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information ) <br /> 1. la PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �-- <br /> For July 1, June 30. 19 l Disposal Sites <br /> Description(MakeNt.,Color)T <br /> Serial No. CAL. License No. CAL. License Renewal No. n <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD T <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 Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Ownerpr Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL JAI LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY P�NEW REPAI OTHER / <br /> 5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> NIT.-Of Uriits Equipment Sto6ge/Cleaning Location(s) ® 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 C. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. A- <br /> 0 DRY CLEAN I NG,.Chemicals Used/Amount/Mo. <br /> Hoarse owns orlicensed agent's sfoneture"Ttifros the follow,.":"I certify that In the performance of the work for which this permit is issued.I shall not employ any person <br /> in such manner as to become subject to workma65 c:unpensail.a laws o!Califnou!" <br /> Corr oactor's hiring or sub-contracting signature eoetfins the following: I certify that in the performance of the work for which this permit is Issued.I shall <br /> employ persons subject to workmans compensallon laps ul 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 an.0 regulatrgns of the San Joaquin 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 a Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS i <br /> PENALTY Af <br /> OTHER <br /> OTHER <br /> Receives by Date Rmeipl No. Permit No. Issue ce Date Mewed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 25MI <br />