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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .. APPLICATION <br /> y (For Non-Transferable,Revocable,and Suspendable) SEPTAGE, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby made to carry on bu mess in the wris ictional area of the Sa Joaquin Local Health District <br /> Business Name ( Address <br /> i Owner <br /> �Adess <br /> d <br /> 3 Firm Partners, Addresses and�Telephone Numbers <br /> E Business Telephone No. �� -� Emergency Telephone No. <br /> Contractor Licence No. 2_ <br /> Applicants Name (Print) Title — Date <br /> Please check Applicable Category (1-7) and t=ill in the Requ ed 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 <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.C.E.No. <br /> Testi L ation Test Date/Time <br /> 4. u SANITATION PERMIT <br /> Job Address/Location .2-7 9 <br /> Owner r Address g <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ L19CHING FIELD � SF PAGE PIT ❑ PACKAGE PLANT 23/ n' <br /> ❑ PERMANENT 131:1 , <br /> TEMPORARY NEW 'REPAIR ❑ OTHER i <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 /> Operator Name Where Certified <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 /> 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, and rule and regulation th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> J`BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �[ <br /> �y H ,� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE. P.O.Box 2009 $TOCKTON,CA 95201 - <br />