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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> y , (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> <' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ispy-made to c on btsine in the jurisdictional area of the San Joaquin Hea Yh District <br /> 4 <br /> rn Business Name (DBAddress <br /> © <br /> aOwner Address <br /> Firm Partners, Addresses and TTele hone Nu hers - <br /> aBusiness Telephone No. "� � Emergency Telephone No. <br /> -J Contractor Licence No. - <br /> L Applicants Name (Print) Title Date {1 <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 /> 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. No. <br /> R.S. or R.C.E.Name <br /> Test 4ocation <br /> Test Date/Time <br /> 4.rKSANIT4TION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD klr-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TtMPORARY ❑ NEW OREPAIR ❑ OTHER <br /> 5. ❑r CHEMICAL TOILETS For July 1,_-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name t Where Certified ' <br /> Plant Location t <br /> Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY for Jul '11-t :June 30, 19 ''. <br /> SIZE: ❑ Less Than 1,000 Sg'. Ft., .❑ More Than 1,000 Sq. Ft. r <br /> '❑ DRY CLEANING, Chemicals Used/Amount/Mo. _F <br /> thea sarnrero lim srt �> sAr*tpliQrr6rg"l ixrititY tlfat lAlfieparfCrn1a11�e4fiheltirirlt frAwMCRthispermit is issued,l Shall not employ any pemon <br /> f in such matater as t>ibet als to wFrkltratis cmixnsathm taros otca tfiltmia , <br /> C awls ft" or bmb►tarselrat 0 suers cwdf x ft hllowlrryl; '#tNtifY that ib the peMatlttanct of the work for which this permit is issued,I shall <br /> employ persons subject towarkmalf9coevasawn lamofcaftmia." <br /> hereby certify that I have prepared this appligation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule regulatioA of the Sa oaquin Local Health Distri't, ' <br /> APPLICANT'S SIGNATURE X r _ - <1- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT: ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> --... - ..-. .. REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> . _DATE, DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> '. PLUS �'G�� c CCT c0iC• _ - <br /> PENALTY a _.- <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. 1Permit No. '. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />