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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 PERMIT <br /> x LIQUID WASTE <br /> Application is he made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> O Business Na (DBA) Address <br /> aOwner, Address - — <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> 47 <br /> LApplicants Name (Print) Title Date <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., Calor) <br /> Serial No. -CAL. License No. CAL. License Renewal No. <br /> Capacity _ Gal., Weights &Measures No. <br /> Equipment Parking Address _ _ y <br /> 2. ❑ PUMPER YARD <br /> For July 1,_ •June 30, 19 t ti J <br /> No. of Vehicles Stored t �+ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST k i <br /> R.S. or R.C.E. Name ___ R.S.or R.C.E. No. <br /> Test Location ' Test Date/Time t <br /> 4. ❑ SANITATION PERMIT i r <br /> Job Address/ cation <br /> jw,ner / D 4t#, by - -- Address <br /> SEPTIC NK CESSPO 7-04_- <br /> - EACHiNG FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> k <br /> PERMANENT ❑ TEMPORARY EW { EPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Ju a 30, 19 <br /> Type Construction Disposal Site _ C5 <br /> No. of Units Equipment Storage%Cleaning Location(s) > <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name M Where Certified <br /> Plant Location <br /> Plant Capacity 71 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.i <br /> ❑ DqqY CLEANING Chemicals Used/Amount/Mo. <br /> F! oM rNr N(=roansed sgersYs sFgnatll►w cextilibeilhp fottawlring;"I ctrti#g�fiat in ff►crfa►martca of tfle Werk fnr whkf4lhis perm#f is issued,f shall not employ any person <br /> in such manner es to h6corng sable fto workltlan's compensation laws 4f Catilc+rr?ia . <br /> el9 G ersonsstlti ect t�work mns c9 sigKatlere oertitieR lhr. ?oisa:��nr: !oe!tifv fh:1 IR the pl rfbrma e GttRc vlork for vrhsch tT1is permit 15 tssued.I shall <br /> p y p f nrDensation taws of Calilor Iia <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, rut rid re ulations� . e San Joaquin Local Health District. 1 i . <br /> APPLICANT'S SIGNATURE X <br /> 1FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Urj,1 &Received By Jury 31 <br /> ;,/ REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT'DUE CHECKED <br /> AMOUNT <br /> as <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS t c <br /> PENALTY <br /> OTHER �l <br /> s! <br /> OTHER <br /> Received 4y Date Receipt No. Permit No. Is ante Date Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.8o:2009 STOCKTON,CA 95201 <br />