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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Ap-plicatiopis hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Distric6.�•✓1 <br /> m Business Nme (DBA) , e�° /tJo`S Address �� e <br /> j� �... Address c�7 o'Z9 /�� �'h i�A� <br /> a Owner /i• 1'��• � .�•� t1/A/IS , <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. I � Emergency Telephone No. <br /> Contractor Licence No. p Q <br /> Applicants Name (Print) PC I`� Title �'`� Date <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) <br /> r <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ;4 SANITATION PERMIT On <br /> 0 N <br /> Job Address/Location <br /> I $ s. Address ['O�o.tl <br /> Owner <br /> SEPTIC TANK ❑ CESSPOOL.. LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July-1' June 30, 19 i <br /> Type Construction v Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> a Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant 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. Ft. x <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, n rules and.reg lati ns of the-Sart.Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X , <br /> fAI t <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 $Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION 13ILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE - REMITTED AMOUNT <br /> �FES <br /> i• PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a/ 6 <br /> Received by �Dat Receipt No. - Permit No. is anc Dale . Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />