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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is, ere ar n business in the jurisdictional area of the <br /> y <br /> tiSaquin Local Health.-District <br /> Address a <br /> Business Name (DBA) 4 , <br /> t� <br /> a Owner Address <br /> ,. <br /> J Firm Partners, Addresses andtTTle hone umbers <br /> Q Business Telephone No. ' Emergency Telephone No. <br /> 1 <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) �. - <br /> Title Date.,. <br /> Please check Applicable Category (1-7)and lin 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. <br /> CAL. License No, <br /> CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> i <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 /> Te t Location Test Date/Time <br /> r <br /> 4. SANITATION PERMIT <br />' Job Addre /t ati n <br /> wner Address <br /> jSEPTIC TANK ❑ CESSPO El LEACHING FIELD ❑ SEEPAGE PIT 11PACKAG PLA T <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER p <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type ConstructionDisposal Site <br /> No. of Units N Equipment Storage/Cleaning Locations) . <br /> Is. © PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> k Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 - <br /> SIZE: 11Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft " <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> crLry®oa! ,� �li�ttY�d s >�v trrrc°over.�&�lc direc� <br /> �vnr/c o Iwo <br /> �arf�r auric% <br /> Allow*�j fran,�V,sus e e� .•� '�/���t & <br /> P. �• / rvr. Gf���vr .s �►iriWh wry Sass y/a�.�t /ft/�1 c . <br /> I hereby certify that I have par this application and that the work will be done in accord `Jt San Joaquin County <br /> ordinances, state laws, a tl rul r ti of t e San Joaquin Local Health District. V <br /> APPLICANT'S SIGNATURE'X <br /> 01/ <br /> C",Lo,—01 <br /> FOR DEPARTMENT USE ONLY > <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive d�y January 31 ❑ July 1 &Received By July 31 <br /> / REMIT <br /> BASE EXPLANATION BlLL1NG REMITTAL /$ AMOUNT DUE CHECKED <br /> DATE D TERE ITTED AMOUNT <br /> V <br /> FEE L!/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - `� <br /> ' E '` 3 <br /> OTHER '� i <br /> OTHER 4 . <br /> Received,by Date Receipt No. Permit No. - I suan e a ail Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1661 E.HAZELTON AVE.,P.O. x 2009 STOCKTON,CA 95201 <br />