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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE Y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio 's her y ade to car on usiness in the jurisdictional area of the San Joaquin Local Heal Dl's is <br /> NBusiness Name (DBA) Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numb rs <br /> a. Business Telephone No., i Emergency Telephone No. <br /> Contractor Licence No. r.Y <br /> L Applicants Name (Print) Title .,, Date.. <br /> Please check Applicable Category.(1-7)and-fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I ; <br /> For-July1;-- _--'-;',June-;', <br /> ' `June 30, 19'- �'4 � - = Disposal sites=- --- T • -- --- --�--� - - <br /> Description(Make/Yr.,Color) <br /> Serial No. Y CAL. License No. CAL. License Renewal No. <br /> Capacity "Gal.,Weights &Measures No. <br /> Equipment Parking`Ad&ess <br /> r <br /> 2. ❑ PUMPER YARD.? T <br /> For July 1, June 30,19 734 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST 6 x <br /> R.S. or R.C.E. Name � R.S. or R.C.E. No. <br /> 1 <br /> Test Location ( Test Date/Time t <br /> 4. ❑ SANITATION PERMIT fr, } <br /> Job Address <br /> /L <br /> ion <br /> Owner — (" Address _ T <br /> SEPTIC TANK ❑ CESSPOOL `LEACHING FIELD El PIT PACKAGE PLANT <br /> _ <br /> PERMANENT ❑ TEMPORARY - EW:"'"—--- 'REPAIR --'" O—OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Jun 30, 19 <br /> `Type ConstructionDisposal-Site <br /> No. of-Units -_ y i! x. Equipmeit-Storage/Cleaning.Locat_ions)k'!� Q <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 {. _ t ! r: <br /> Operator Name Where Certlfle <br /> Plant Location <br /> Plant Capacity No. Units Served Y f rR <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 4- f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., © More Than 1,000 Sq. Ft. <br /> I �. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ; <br /> I hereby certify that I have prepared this application and that the work will be done in'accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatiof the San Joaquin L cal Health District. I d,_- <br /> APPLICANT'S SIGNATURE X 0 0- n!f 24—. <br /> • } FOR DEPARTMENT.USE ONLY. <br /> Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑,Ja <br /> nuary 1 &Received By.January 31 El July 1 &Received By July 31 <br /> Y BILLING REMITTANCE $ _ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT { <br /> FEE <br /> ffiS <br /> LESS <br /> PRORATION A <br /> PLUS f 'y <br /> PENALTY - ( z/ — 9 r <br /> OTHER <br /> OTHER. <br /> Received by Date Receipt No. Permit No. Issuance Date Marled Delivered <br /> - APPLICANT—RETURN ALL COP4ES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> x <br />