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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 <br /> ENVIRONMENTAL HEALTH PERMIT - <br /> - LIQUID WASTE , <br /> Appl ication i hereby made to carry on business in the jurisdictional area of the San,loaquin Local Health District <br /> -�� Address <br /> Business Name (DBA) -� <br /> z Owner _.-fAddress <br /> a <br /> 1 <br /> Firm Partners, Addresses and Tele hone tubers Emergency Telephone No. <br /> aBusiness Telephone No. X <br /> Contractor Licence No. E Z2 Title ,,yam�,� pate <br /> �, `1V <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill In the Required Information %_ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �l <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 /> ` Y " <br /> Gal:,-Weights &Measures No. <br /> Capacityl <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 a <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name _ f <br /> ' Test Date/Time <br /> Test Location w <br /> 4. ❑ SANITATION PERMIT � <br /> Job Address/Location i <br /> G - - Address C l <br /> Own-W �A ❑ PACKAGE PLANT <br /> O SEPTIC TANK ❑ CESSPOOL U�.t CHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ' ❑ PERMANENT TEMPORARY ❑ NEW 1:3 REPAIR <br /> 5. ❑ CHEMICAL TOILETS For.July 1 June 30, 19 <br /> %„ <br /> Type Construction-, Disposal Sitet <br /> No.-of Units _ " x ;��Equipment Storage/Cleaning Location(s) <br /> f <br /> t . ,. _ <br /> k 6. ❑ PACKAGE TREATMENT PL-ANT—For July 1, -June 30, 19 Where Certified _ "+ <br /> Operator Name <br /> Plant Location ` <br /> r <br /> No. Units Served <br /> Plant Capacity <br /> I 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 /> w n y <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 r ul ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Y <br /> C <br /> I FOR DEPARTMENT USE ONLY <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JuTy`31 <br /> REMIT`: <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE. CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE y� <br /> LESS <br /> I' PRORATION <br /> Y PLUS. <br /> " PENALTY <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issua ce Date- Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO:" ENVIRONMENTAL HEALTH PERMLT/SERVICES 1901 E.HAZELTON AVE.,P.O.Box 2l]09 STOCKTON.CA 95201 <br />