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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign inewppimutwil. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 2 LIQUID WASTE <br /> Application is hereby made to arry on business in the jurisdictional area of the San Joaquin Local Health District <br /> .F. Business Name (DBA) <br /> + Address <br /> I- .! Address �`--`— <br /> z Owner <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a Z <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please checic 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., Calor) 1 <br /> Serial No. A CAL. License No. CAL. License Renewal No. <br /> Capacity— Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i,_ June 30, 19 I <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored c ,t <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time W <br /> Test Lo tion 1� <br /> 4. u SANITATION PERMIT <br /> Job Address/Locati n <br /> Owner ' -�- Address <br /> Q'5 PTIC TANK ❑ CESSPOOL LEACHING FIEL4 PAGE PIT El PACKAGE PLANT <br /> llY PERMANENT E] TEMPORARY ❑ NEW F REPAIR 11 OTHER r r= <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 „ 1—7/ <br /> Disposal Site <br /> Type Construction <br /> Equipment Stora Storage/ Location(s) <br /> No. of Units9 g ( p- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 AI, <br /> --- -- Where Certified <br /> Operator Name <br /> Plant Location A-V <br /> Plant Capacity '.No.,Units Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq-Ft.— <br /> f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. /// <br /> t <br /> f <br /> i <br /> 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 'ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT.USE O <br /> Fee Is Due- ❑ ANNUAI LY PER UNIT ❑ PER SITE © EACHary 1 &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING R,RE ANCE f $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE HIS <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C7 _�--3aS '/ y 2 � <br /> Received by Date Recei No. Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SE�iVICES 160 E.HA ETON AVS O�2 - STOCKTON,CA 85201 R <br />