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_ 1-�_ _ <br /> Applications Will Be Processed When Submitted ProperlyCOmPleteo. <br /> APPLICATION . <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District �- <br /> r Ad ress _ <br /> Business Name (DBA) <br /> u, Address <br /> z Owner <br /> a <br /> j Firm Partners, Addresses and Telephone Number ergency Telephone No. <br /> aBusiness Telephone No. Y <br /> Contractor Licence No. _ Title Q Date <br /> LApplicants Name (Print) <br /> ,Y <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) CAL. License Renewal No, <br /> Serial No. CAL. License 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 /> t 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name - �- Test Date/Time <br /> Test Location ` <br /> 4. ❑ SANITATION PERMIT Uc <br /> L y�v <br /> Job Address/LQcation <br /> I <br /> � Address PACKAGE PLANT <br /> Owner LEACHING FIELD ❑ SEEPAGE PIT SEPTIC TANK TANK ❑ CESSPOOL L ` <br /> ❑ OTHER Nom+ <br /> PERMANENT ❑ TEMPORARY XNEW ❑ REPAIRcy`, 3 <br /> c <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site <br /> Type Construction <br /> ` No. of Units Equipment Storage/Cleaning Locations) <br /> ( 6, ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name _ r <br /> Plant Location Y <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: 13 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> liornaovinerorllcensedatieht'ssignt+turccrrritirsihPsc?lewinr.:1certifythatil!theoerformarceaF? oe��I,e 'cle v4 klorh this which I slpemiti5i su4d,Isha�rs4n i[ <br /> :(ol}ri}31i5i.0,ii�n515&hOf wtl5^ {'e'll. ^:f,' <br /> Irl stiCh!Tla!1R®T a5 to becc;l subject - 4c.F'�;; I L :il'- "at in,h,Pel <br /> r <br /> Contractor's hiring or suircon ec i�c s °a atic�i y y <br /> emplCy persons subicrtlC Wi Ik!748r CC;1rBi13 ':``:° <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-4aa�r�a�nd r 's and ulati ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 4 <br /> .FOR DEPARTMENT USE ONLY <br /> Fee IS DUE: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceireREMIT <br /> $d By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> LESS v <br /> PRORATION <br /> . .._ .x <br /> PLUS <br /> PENALTY ' <br /> k OTHER <br /> ~OTHER <br /> L Permit No- Issuance Dat Mailed Delivered <br /> Received y Das Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> 1641 E.HAZELTON A .,P.O.box 2009 STOCKTON,CA 95201— <br />