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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 9 <br /> Application is hereb ma QjgaW onppsiness in the jurisdictional area of the San Joaquin Local Health District f <br /> rn Business Name (DBA) Address T a <br /> aOwner ... :.._ Address <br /> Firm Partners, Addresses and elephone Numbers <br /> CL EL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) -. Title __ .df- Date r <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 aM - Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. 1 <br /> Capacity Gal., Weights & Measures No. --- \ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Testi Loc tion ' Test Date/Time <br /> 4: Pd SANITATION PERMIT ] _ <br /> Job Address/Location "� G" <br /> Owner 1>A,,VA �J11 ' %Add1ess �,r,T <br /> [I"SEPTIC TANK 11 CESSPOOL! Q-11ACHING F41=1_D ❑ SEEPAGE PIT ❑ PACKAGE PLANT r <br /> T "❑ PERMANENT ❑ TEMPORARY 11!NEW t ° ❑ REPAIR �, '❑ OTHER <br /> 5: ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> V11 <br /> T,ype Construction l - `Disposal Site <br /> No. of Units i Equipment-Storage/Cleaning Location(s) <br /> 8. ❑ PACKAGE TREATMENT PLANT FoeJuly 1, June 30-rt19 s <br /> Operator Name: Where Certified <br /> s ' <br /> Plant Location • _ , <br /> 0,1ant Capacity No.•Units;Served <br /> 7' ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Than 1,000 Sq. Ftp f <br /> DRY CLEANING, Chemicals Used/Amount/Mo. 1 <br /> r <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 gulat�-of,the San Joaquin Local Health District. <br /> .A ) <br /> PPLICANT'S SIGNATURE X �` '- <br /> 0 47 <br /> L FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &NReceived By January 31 ❑ July 1 &Received By July'31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE ii EXPLANATION - DATE DATE REMITTED k' AMOUNT DUE CHECKED <br /> AMOUNT ? <br /> FEE <br /> s <br /> LESS <br /> PRORATION <br /> 1 PLUS <br /> PENALTY <br /> dv <br /> t C <br /> { OTHER <br /> } OTHER <br /> _. it <br /> Received by - - Dale Receipt No. Permit No. Issuanc at __ -Mailed _ Delivered _ <br /> �.. <br /> APPLICANTS RETURN ALL COPIES TO: {ENVIRONMENTAL HEALTH PERMIT/SERVICES �-'¢'1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br />