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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~P.ERMIT <br /> LIQUID WASTE <br /> Application is h reby made caon business in the jurisdictional area of the Sa /Qjaqui <br /> ocal Hea District <br /> v .✓ P <br /> OF Business NameEd <br /> ) , � � 'Address <br /> i Owner Address l <br /> Firm Partners, ses and elephone Numbers f <br /> CL Business Telephone Nv. 6 Emergency Telephone No. <br /> aL. <br /> Contractor Licence No. te ,,/} <br /> a !� t <br /> LApplicants Name (Print) ;:., Title Da, <br /> Please check Applicable Category (1-7)and FI 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., T,T <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATIONITEST <br /> R.S. or R.C.E. Name <br /> i R.S.or R.C.E. No. <br /> Test Location t Test Date/Time <br /> 4. A SANITATION PERMIT <br /> Je i <br /> o ddress/Coca 'on <br /> ner r F J Address �� <br /> SEPTIC TA 0 CESSPOOL! ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ' ❑ TEMPORARY ❑ NEW RV.AIR ❑ OTHER <br /> ca <br /> 5. ❑ CHEMICAL TOILETS For July 1,,June 30, 19 <br /> �'T" ` Disbsal Site <br /> Type Construction p <br /> No. of Units Equipment Storage%Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT F6i.July,1, -June 30, 19 f ' <br /> Operator Name - - ti Where Certified <br /> Plant Location t `� <br /> Plant Capacity s^ No. Units Served <br /> 7. ❑ LAUNDRY For July 1 June 30,-19- <br /> SIZE: <br /> 0,19SIZE: ❑ Less Than 1,000 Sq Ft., ❑ Mo-'re:-Than 1 <br /> J-Than ,000 Sq. <br /> 11 DRY CLEANING,Chemicals Used/Amount"'M.. <br /> !#ome.ewnerorlicensed e9ent'sfn!IoMrip.-1 certifv{haf in the performa noeco!the wGrk'for::hirh this permit isissued,f shall not em",loy anypers, <br /> in such manner as to bec,ma subjer`to vjeri.rr.T.1's earlpensaticn laws to("d <br /> t,-! lil' <br /> Contrictor's hir€nq or crib-contra ting sicn&tura: cz)rlitias the faetawieg: `l tartify mal in the perfGn;;ance of lite work fOT Alch this ra, '.it is Issued,15i w! <br /> employ persorm subject to workman's compensation laws of Cafifomia." t <br /> 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 regulatio of the S p Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> G-cc, t-- <br /> FOR DEPARTMENT USE ONLY ; <br /> Fee Is Due: ❑ ANNUALLY, ❑ PER UNIT ❑ PER SITE ❑ EACH I ❑ January 1 &:Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION- BILLING 'REMITTANCE $ AMOUNT DUE CHECKED <br /> �.£, DATE. 1 GATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> h • <br /> OTHER + .. Wim. -•� - . <br /> OTHER <br /> Received by - Date - _ Receipt No:: Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTWPERMITIE ERVICES 1601'E.HAZELTON AVE.,P.O.-Boa 2009 STOCKTON,CA 95201 <br /> k <br />