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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 on business in the jurisdictional area of the San Joaquin Local Health District�C` <br /> �n Business Name DBA) / > ��` Address �� r11e '4 <br /> a Owner <br /> �� Address Qi <br /> 0 Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. Rf— Emergency Telephone No. I <br /> Contractor Licence No. ^ �1J Date 3"� <br /> Applicants Name (Print) A 1 f� Title <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) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &YMeasures No. <br />'I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June'30, 19 <br /> No. of Vehicles Stored <br /> No- of Chemical Toilets�Sf6red -, .. <br /> 3. ❑ PERCOLATION TEST. s <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location r. <br /> Test Date/Time <br /> 4, ❑ SANITATION PERMIT } ,: <br /> Job Address/Location !p / .... <br /> O�w/ner � - - - - Address <br /> L�SEPTIC TANK ❑ CESSPOOL""`'4 "',9' ACHING FIELD ❑ SEEPAGE IT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ":❑ NEW ❑ REPAIR ❑ OTHER ? <br /> 5. ❑ CHEMICAL TOILETS For'July�l, -June 30, 19 µ <br /> Type Construction k Disposal Site <br /> ` 4 <br /> No. of Units Equipment Storage/Clean ing_Loaation(s) <br /> 6. ❑ PACKAGE TREATMENT-PLANT''=�Fd-r July 1, -June 30,'19 Li , <br /> Where Certified <br /> Operator Name d <br /> Plant Location <br /> Plant Capacity 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 /> I hereby certify that i have prejlared'this application and�that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and relations of the>SarpJoaquin Local Health District. <br /> i <br /> i APPLICANT'S SIGNATURE X i <br /> FOR DEPARTMENT USE ONLY4.4 ' <br /> Fee Is Due: [3 ANNUALLY ❑ PER UNIT ❑ PER SITE EACH:. ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> s BILLING, r REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED ^� AMOUNT <br /> FEE _ <br /> LESS <br /> PRORATION -�--- <br /> k PLUS ` <br /> ( PENALTY <br /> OTHER - -- . <br /> OTHER- - <br /> SS 3 afX I 3 <br /> xA Received by <br /> Date Receipt No. - Permit No I uance ate Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA-952 <br /> APPLICANT—RETURN ALL COPIES TO' <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />