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operly Completed. Be SureTo SignTheApplication. <br /> Applications Will Be Processed When Submitted Pr <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h y,mnade to on b sines in the jurisdictional area of the San Joaquin Local Health Di irr <br /> yBusiness Name(DBA) ►19 / Address <br /> F ! Address <br /> a Owner ; <br /> Firm Partners, Addresses and Tel,9phone Numbe s <br /> a [ _5 - �, Emergency Telephone No. <br /> a Business Telephone No. - <br /> Contractor Licence No. <br /> Applicants Name (Print) �� ! Title Date <br /> p € <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, 194 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. .CAL License No. CAL. License Renewal No. <br /> Capacity lI Gal., Weights & Measures No. <br /> Equipment Parking Address__ 1 <br /> 2. ❑ PUMPER YARD <br /> li <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I <br /> No. of Chemical Toilets Stored . <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name { <br /> ` Test Location T Test Date/Time <br /> 4. C1 SANITATION PERMIT ! ` en ' <br /> Job Address/L cation G+ <br /> Owner '' / ` Address <br /> SEPTIC TANK .. ❑ CESSPOOL 'LEACHING FIELD C3 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT El TEMPORARY �1EW ❑ REPAIRGOTH R `Q <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t LW <br /> Type Construction 4 Disposal Site - <br /> No. of Units IIII Equipment Storage/Cleaning Location(s) - <br /> TD <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30-19 <br /> f r" ■"" ~ ' Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity SMI No. Units Served <br /> 7. ❑ LAUNDRY For July i, I�June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r i <br /> I hereby certify that I have preparel9 Is a ication a that the work will be done in accordance with San Joaquin County _ <br /> t ordinances, state laws, and rul d regul Ions oft San Joaquin Local Health District. r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY Y <br /> Fee IS Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE ^ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIITuly 31 <br /> IM BILLING REMITTANCE $ AMOUNT DUE. CHECKED <br /> BASE EXPLANATION DATE DATE � 'REMITTED.- AMOUNT <br /> Ar <br /> Date - Receipt No. Permit No. issulaceMaie Mailed Delivered <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV .Box 2009 STOCKTON,CA 95201 <br />