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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I� -Z - - APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE r <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 <br /> yBusiness Name (DBA) Address <br /> z Owner <br /> a Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - - <br /> L Applicants Name (Print) Title Date <br /> Please check Applicabie Category(1-7) and Fill in the Required Information t; 'f. I F <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. ,x <br /> Equipment.Parking Address ,A <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 �` •+ <br /> No. of Vehicles Stored <br /> ,r No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> x n <br /> R,S, or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. .❑ SANITATION PERMIT ( } <br /> Job Address/Location j <br /> Owner <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL. ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT4 <br /> ❑ PERMANENT ❑ TEMPORARY, ' - ❑ NEW ❑ REPAIR ❑ OTHER a r <br /> 5. ❑ CHEMICAL TOILETS For July I,'-' <br /> June 30, 19 <br /> Type Construction ' ' "�' Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.1, -June 30, 19 <br /> Operator Name Where.Certified <br /> } <br /> Plant Location � <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -`June:30, 19 <br /> d <br /> SIZE: '❑ Less Than 1,000 Sq. Ft`40 More Than 1,000 Sq. Ft. 4 .. <br /> d I # <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4-.4 <br /> I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin County I <br /> ordinances, state laws, and rules and regulations of the�San"Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �F,.. <br /> FOR DEPARTMENT USE ONLY r <br /> Fee IS Due: ❑ ANNUALLY ❑ AER UNIT El PFR SIT El EACH ❑ January 1 &Received By January 31, ❑ July i &Received By July 31 <br /> ' BILLINGREMfT7ANCE !a$ n - REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE g DATE REMfTTED <br /> AMOUNT <br /> FEE . <br /> LESS s 4 ,Z it <br /> PRORATION <br /> PLUS ` <br /> PENALTY } <br /> OTHER 1 <br /> OTHER <br /> Received by Date Receipt No, Permit No. .� Issuance Date Mailed Delivered " <br /> APPLICANT—RETIIRN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '7601 E.HA2ELTON AVE.,P.O.BOR 2009 STOCKTON,CA 95201 <br /> /� <br />