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Applications Will Be Processed When Submitted Property Completed. Be u <br /> APPLICATION � <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> 159 <br /> Applicata n is hereby de car busin s in the jurisdictional area of the Sa_p�loagoin Local Health District <br /> e Address �� J �I <br /> rBusiness <br /> Q Owner e t �` A dress <br /> c e [ L€ <br /> Firm Partners, Addresses and Telephone 3 NumberIII s <br /> Emergency Telephone No. <br /> i a Business Telephone No. � 7 <br /> Contractor Licence No. � <br /> L G[. Date <br /> Title <br /> Applicants Name (Print) <br /> C <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION <br /> FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites . <br /> Description(Make/Yr., Color) CAL. Liccnse Rencwal No. <br /> Serial No. <br /> CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, ,lune 30, 19 � <br /> No. of Vehicles Stored <br /> Ik No. of Chemical Toilets Stored N <br /> i 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> 1 R.S.or R.C.E. Name <br /> l.. Test Date/Time <br /> Test Location <br /> 4. tU'SANITATION PERMIT ' C_ <br /> Job Address/1-0,0ation. • X] �,� r _ <br /> Owner Address <br /> I ❑ CESSPOOL Cl LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT- <br /> 0 <br /> LANT <br /> ❑ SEPTIC TANK <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW 11 REPAIR 11 OTHER <br /> ` 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> ( Operator Name <br /> I Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pr r this appli on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and le d regulatio 0 e an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r. BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> r ' ` _ JJ - 4 qS <br /> ` <br /> FEE `5 tS <br /> LESS <br /> PRORATION �(} <br /> PLUS j <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance Date Mailed Delivered... F <br /> Date Receipt No, Permit No. - <br /> I Received'by - 1601 E.HAZELTON AVE_P.O.Box 2009 STOCKTON,CA 95201 <br /> !- APPLICANT—RETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES <br />