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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 ' r made car bu 'ness in the jurisdictional area of the San Joaquin Local Health Distr Ct; <br /> rn Business Name (DBA) � Address <br /> i Owner Address <br /> 2 Firm Partners,Addresses and Telephone Numbers <br /> I a Business Telephone No. � Emergency Telephone No: - <br /> Contractor Licence No. <br /> Applicants Name (Print) v "n' - Title _ �g�` Date 1+ <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. License Renewal No. <br /> Capacity { Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD` <br /> For July 1, June 30, 19 - v <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.0-E. No. <br /> Test�LP cation Test Date/Time <br /> 4. <br /> Test <br /> PERMIT <br /> Job Address/Lo ation �'•"� � <br /> Owner - Address <br /> { ❑ SEPTIC TANK ❑ CESSPOOL Pa LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT y <br /> PERMANENT ❑ TEMPORARY ❑ NEW {}{_REPAIR ❑ OTHER !" <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> 4 Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity µ 14 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t - <br /> hereby certify that I have preparsd-4 is a- I' ton a d that he work will be done in accordance with San Joaquin County <br /> ordinances, state iaws,,and rul a g 'ons of the an J gyin Lo I Health District. <br /> APPLICANT'S SIGNATURE X <br /> os <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY ❑ PERY UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> F BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �j S L <br /> LESS <br /> PRORATION <br /> PLUS l� �! <br /> 4 PENALTY �n1 <br /> OTHER f !d <br /> OTHER <br /> Received by Date Receipt No Permit No. I suance Date Malled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMITISERVICES 16011 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />