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Applications Will Be Processed When Submitted Properly Completed. a ure o <br /> z � - APPLICATION <br /> (For Non-Transferable;,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> LIQUID WASTE <br /> Application is her y made to carryon bus' ss in the jurisdictional area of the J uin Lgc l Health Di - D <br /> Addres <br /> �n Business Name (DBA) <br /> Address <br /> j z Owner <br /> a <br /> Firm Partners. Addresses and ele hone u�ers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. <br /> " Title �^ Date <br /> + �Applicants Name (Print) W <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.,-Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> ! Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address + <br /> 2. ❑ PUMPER YARD <br /> t For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> r No. of Chemical Toilets Stored N.- N <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> ' R.S. or R.C.E. Name <br /> Test Loc n Test Date/Time <br /> q. L� SANITATION PERMIT <br /> Job Address/Location <br /> Owne Address <br /> �� ❑ CESSPOOL ❑'EACHING FIELD E SEEPAGE PIT 11 PACKAGE PLANT <br /> I L'1 SEPTiC TANK ❑ REPAIR ❑ OTHER <br /> O PERMANENT ❑ TEMPORARY ©�W <br /> 5. ❑ CHEMICAL TOILETS .For July 1,-June 30, 119 - — ,T <br /> Type Construction _ Disposal Site <br /> `r No. of Units Equipment Storage/Cleaning Locations)r <br /> t 6. ❑ PACKAGE TREATMENT PLANT, For July 1, -June 30, 19 Where Certified <br /> Operator Name w <br /> t Plant Location No. Units Served <br /> Plant Gapacity \ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> i SIZE; ❑ Less Than 1,000 Sq. Ft., $❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> L <br /> I hereby certifyahat In prepared this applica ' n an t at the work-will be done in accordance with-San Joaquin County <br /> ordinances, state laws, d ales an guiatio the . oaq in Local Health District- <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> January 34 July 1 &Receivedufy 31 <br /> Fee Is Due' 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By ❑ REMIT <br /> • BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> . Do r <br /> LESS <br /> PRORATION + <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> C.Grp_ <br /> Receipt No.: � Permit No. Issuance Date + Mailed Delivered <br /> Redelved by Date .. - <br /> _-APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT_/SERVICESR 1691 E.HAZEITON AVE.,P.O.Bow 2609 -STOCKTON,.CA 85201 <br /> ' — <br />