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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendabfe) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her by made tcar on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) Address <br /> z Owner . - Address <br /> i a <br /> Firm:Partners,Addresses and Telephone Numbers _ <br /> i 0. Business Telephone No. - j Emergency Telephone No. <br /> r -i Contractor Licence No. <br /> LApplicants Name (Print) uLL Title. Date <br /> i <br /> Please check Applicable Category(1-7) and Fill in the Required Information O <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 v 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 /> Test,,.,'Lo�ccation Test Date/Time <br /> 91 ' <br /> 4. --SANITATION-PERMIT._, <br /> # Job Address/Location T A - <br /> O�w/ner. Address <br /> Its SEPTIC TANK ❑ CESSPOOL 0-'COACHING FIELD 11 SEEPAGE-.PIT— ❑ PACKAGE PLANT e <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW WIREPAIR- ❑—OTHER ' U) <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19—Disposal-Site <br /> " <br /> Type Construction P� , <br /> E ui ment Stora a/Cleanin Location s) ) ' <br /> No. of Units q P 9 9 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity - ` ` a No Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 3 - -�•-�-f--�� i t, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEAN ING,,Chemicals-Used/Amount/Mo: <br /> hereby certify that I have_prepared..this-a plication and that the work-will-be'done=in accordance with San Joaquin County <br /> ordinances, state laws, a4rullees and re ati s offtthe <br /> �Saann'.Joaquin,Local HealtirDistrict. r °' <br /> APPLICANT'S SIGNATURE X -��_- --•� ° ;,,4 <br /> 441 <br /> a <br /> ! FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY; ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 s ❑ July 1 &Received By July 31 <br /> _ ,e REMIT <br /> f. ; BILLING REMITTANCES AMOUNT DUE CHECKED <br /> ! BASE EXPLANATION <br /> j[)AT-F -�—DATE-?I-r- REMITTED AMOUNT <br /> FEELESS <br /> PRORATION - <br /> PLUS <br /> t PENALTY <br /> OTHER , s <br /> I <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 91201 <br /> s <br /> " s - <br />