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Applications Will Be Processed When SubAPPLICATIONProperly Completed. . <br /> �_ (For Non-Transferable,Revocable, and Suspendable) SEPTAGE ° <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i ruby made carryon iness in th juns ctional area of the S �aq�iin Local Health District <br /> Address ��� ! <br /> NBusiness Name 13A ddress 76 <br /> i Owner <br /> a <br /> Iu Firm Partners, Addresses an-g TelephoneNumbers Emergency Telephone No. <br /> a. Business Telephone No. <br /> Contractor Licence No. Date 22 <br /> ,. -� Title <br /> LApplicants Name (Print) <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 /> Gal., Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Lation - <br /> f 4. Iff SANITATION PERMIT ,. 61 <br /> Job Address ocation Address <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SE GE PIT` ❑ OTHER <br /> ❑ PERMANENT <br /> ❑ TEMPORARY. ❑ NEW EPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �' ." <br /> j Type Construction <br /> 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 /> 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. f <br /> t <br /> , A <br /> tify that I have prepared this application and that the work will be done i accor-ance with San Joaquin County <br /> I hereby cer <br /> ordinances, state laws, and rules regulations of t Sa Joaquin Local Health Distri t. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ON,, <br /> PER UNIT ❑ PER SITE ❑ EACH C1J nua. &Received By January 31 ❑ July 1 &Received By July'31 <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> BILLING REMITTA C $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT. <br /> FEE 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER ✓w <br /> Yo <br /> Date Receipt No. <br /> Permit No, Issuance Date Mailed Delivered <br /> Received by' 1601 E.-HAZELTON AVE.,P.O.Box 2009' STOCKTON,CA 952P4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />