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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 /> LIQUID WASTE <br /> Application is hereby made to carry n business in the jurisdictional area of the n Joaq Local Heaallth (strict _ <br /> yBusiness Name (DBA) Address—fir�� <br /> z Owner Z 15, 0Address <br /> z <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Emergency Telephone No. <br /> CL <br /> Business Telephone No. <br /> Contractor Licence No. !` _ <br /> Applicants 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., Color) <br /> Serial No. CAL. License No. CAL. Lic;cae 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 . <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST > <br /> 7' R.S.-or R.C.E. Name R.S. or R.C.E. Na <br /> Test Location ' Test Date/Time <br /> 4. ❑ SANITATION PERMIT �- <br /> : � G <br /> '. Job Address/Location—_ <br /> O,wn�r f� �W Address _ <br /> Ud'SEPTIC TANK ❑ CESSPOOL LEACHING FIELD c❑--,, SSE�E��EPAGE PIT ❑ PACKAGE-PLANT i <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �HtPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,19 <br /> Type Construction r Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -- ------ _ Where Certified <br /> Plant Location,. - - <br /> 's``'`� i► ``" No. Units Served <br /> Plant Capacity <br /> 7. 0'1tA6NDRY For;July 1{ June 30, 19— <br /> SIZE: <br /> 0, 19 SIZE: ❑ Less T{a11,,000:5q. Ft., ❑ More Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> I - <br /> ! i hereby certify that (''have prepared this application and that the work will be done in accordance.with San Joaquin County <br /> ordinances, state laws, and rules and regulati of th an Joaquin Local Health Districtw- E <br /> APPLICANT'S SIGNATURE Xa <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ''❑-.January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE e $' AMOUNT DUE CHECKED v <br /> DATE DATE REMITTED AMOUNT <br /> { FEE <br /> 1 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY T <br /> r OTHER V' <br /> OTHER <br /> i <br /> o3-S t <br /> Received by L Date Receipt No. Permit No- Issuance ate' Mailed Delivered <br /> y, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NAZELTON AVE.,RO.Box 20119- STOCKTON,CA 95201 <br />