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Applications Will Be Processed When Submitted Properly Completed. Be sure <br /> - . <br /> ..=APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ! <br /> Application is hereby made to carry on business in the jurisdictional area of then Joa uin Local Health District <br /> Address <br /> U) Business Name ( BA) Address w� i <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> j Contractor Licence No. .- Title Date <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Informations <br /> j rW� <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 Disposal Sites , <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. � <br /> ' Gal.,Weights 11 Measures No, <br /> Capacity <br /> Equipment Parking,Address <br /> 2. ❑ PUMPER YARD <br /> t For July 1, rJune 34, 19 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> 5`F <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location t <br /> 4. ❑ SANITATION PERMIT - <br /> Job Address/Location en T lam` <br /> DIP r- Address ❑ PACKAGE PLANT <br /> Owner ACHING FIELD 1:1SEEPAGE PIT <br /> JQ SEPTIG TANK CESSPOOL ❑ REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site '? <br /> Type Construction "` � <br /> Equipment Storage/Cleaning LoA1 ®..� - - �- "- <br /> No. of Units <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1,.Y June;30, i9g Where Certified <br /> s <br /> Operator Name <br /> Plant Location � � '� � -- •• -- <br /> "'1-No._UDits Servedm <br /> Plant Capacity - <br /> 7. ❑ LAUNDRY For July l, June 34, 19 <br /> _ <br /> SIZE; ❑ Less Than 1,004 Sq. Ft., �❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals.Used/Amount/Mo. <br /> Ir <br /> i y TTT lication and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this app <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLI^CANT'S SIGNATURE X ` <br /> k � <br /> L <br /> y FOR DEPARTMENT USE ONLY <br /> By <br /> Feed IS Due: ❑ ANNUALLY ❑3 EMIT <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January} &Received By January 31 July 1 &Received uIy 31 <br /> - BILLING REMITTANCE AMOUNT DUE ,; CHECKED. <br /> .P BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> ' LESS <br /> PRORATION Y-Z <br /> PLUS <br /> PENALTY <br /> .215 <br /> OTHER. <br /> } .. <br /> Sa Oto o- <br /> Permit o. Issuance Date Mailed Delivered <br /> Date Receipt Na- 01 <br /> Receiv by - 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,C <br /> a: APP (CANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES O� - <br />