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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignThe Application. <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 thg Sari.4oaquin LLocal Health District 9 Q� <br /> Address. <br /> Business Name (DBA) <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers' Emergency Telephone No. <br /> aBusiness Telephone No. �^ <br /> Contractor Licence No. Title �`* Date <br /> L Applicants Name (Print) <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. i <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD '7 <br /> For July 1, June 30, 119 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. c � <br /> R.S.or R.C.E. Name Test Date/Time C <br /> t <br /> Test Location <br /> 4. �SANITATION PERMIT <br /> Job <br /> 5� � r <br /> ° <br /> Address/Location L^- j <br /> i Owner Il, Address <br /> 1:1 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT C� <br /> ❑ TEMPORARY 2 REPAIR O�HER -J—IV—r f�VM� -Ss. <br /> G'PERMANENT —T�JJ S.S )4JV0��TI 1> <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 N <br /> Type Construction Disposal Site <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> e 30, 19 <br /> 6. 11 PACKAGE TREATMENT PLAN For July 1,- JunWhere Certified <br /> Operator Name <br /> Plant Location <br /> No, Units Served <br /> Plant Capacity <br /> 1 7. ❑ LAUNDRY For July 1, -June 30, 19 ZG 1��`a -f- " �� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify that l have prepared this application and,that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules d regulns of S311 Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ^ FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT a[] PER SITE ❑ EACH ❑ January 1 &Received By Ja y 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTE AMOUNT <br /> t <br /> FEE ' <br /> Il LESS <br /> ' PRORATION <br /> L <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> OTHER &VQ Mailed Delivered <br /> I� Receipt No. Permit No. IHA nce D _ _ <br /> 1 Receivetl by Date .Box 2009 STOCKTON,CA 95201 <br /> 1601 E.HAZELTO <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Y <br />