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Applications Will Be Processed When Submitted Properly Completed BeSureTO sign Ineskppucauvn. <br /> APRLIC.UION <br /> (For Non-Transferable, Revo able,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> sine sin the jurisdictional area of the San Joaquin Local Health District. <br /> Application is hereby made to carryon bu <br /> aBusiness Name (bBA) - Address <br /> z Owner Address <br /> 4 <br /> Firm Partners, Addresses a T le hone Numb rs <br /> SL Emergency Telephone No, <br /> c a Business Telephone No, <br /> _J Contractor Licence No. ' <br /> L Applicants Name (Print) Title ate s <br /> Please check Applicable Category.(1-7) and Fill 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) _ j <br /> l �s <br /> Serial No. CAL. License No. CAL" License Renewal No. <br /> �..�.a �. <br /> Capacity'"" " _G I7,Weights &'Measures No.— <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored _ _ Y__. . .» _ . . ��-<- - -- -(• - -._'"".," "" 'r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E. No. t <br /> i R.S. or R.C.E. Name <br /> Test Location <br /> Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> oct <br /> O er - Address r • <br /> SEPTIC TANK ❑ CESSPOOL ACHING FIELD `SEEPAGE PIT ❑ PACKAGE PLANT c , <br /> PERMANENT El TEMPORARYr <br /> EW /❑ REPAIR t❑ OTHER ! t <br /> ► f <br /> f <br /> 5. CHEMICAL TOILETS For July 1,- 30, 19 <br /> Type Construction �. -- Disposal Site <br /> I i . <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 # t <br /> Where Certified <br /> Operator Name , , -, I ) <br /> Plant Location { <br /> Plant Capacity r No. Units'Served <br /> 7. ❑ LAUNDRY,-For:luly,l,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq'I Ft., ❑ More Than 1,000 Sq. Ft. ,_k d <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. 'f ` <br /> i <br /> ) kidsnevwncrdrlitensedagant'sFigreturer_ertife5tisefoiioetiing:"I certifythaTin,thi;iierfor:natrrenfthe work forwhicfrthis permit isissuet!.Islzaltnotemploy any ppFsen <br /> in such manner as to become subject to work:rian's compensalioll laws cT�:a:ifnrnis. ( I s <br /> i Contractor's hirirt� or sub-contra�ti- sicnet{:rt C��ti;Eea the foliciu�nq: -'I Certify that in she performance of 1,he work for tv!iclZ i'h.. ort itis i�;,ticd,I shaft <br /> employ persons sLbint to workman' CClrif)L'ri5_eti0i3la71S•ni(,'anter:iii." <br /> s ra ! I 1 <br /> I hereby-eel ' that I'have pre aced this"application and that the,work will be done in accordance with San'"Joaquin County <br /> ordinances, slate. and ules d r gulati s of t Sa oaquin Local Health District. <br /> ;APPLICANT'S SIGNATU <br /> { FOR DEPARTMENT.USE ONLY <br /> Fee IS Due: ❑ ANNUALLY EIPERUNIT El PER SITE ❑ EACH, © January 1 &Received By January 31 El July 1 &Received By July 31 <br /> { REM$T <br /> i J .+ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE $ � <br /> BASE _ EXPLANATION - DATE f DATE - -REMITTED--- AMOUNT <br /> r' <br /> f: � s <br /> i FEELESS r <br /> � p� <br /> PRORATION '� I - ! ' r / T `'�✓p —"�' <br /> / / 1 <br /> PLUS PENALTY s ' r '" : /�K� f '�. C Gf� �c'T- 'l `"��✓ <br /> OTHER - <br /> ' i <br /> OTHER 1 <br /> } <br /> WM 11 <br /> Re eived by e to Receipt No. Permit No issuan a Date Mailed Delivered / <br /> - APPLICANT—RETURN AL'L-COPIES-TO: ENVIRONMENTAL-HEALTH'PERMITISERVICES'— 1601''E:,HAZEL AYE.,�P:O:'Box 2009'�STOCKTON,CA 95201 <br />