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bmitted Properly Completed.Be Sure To Sign The Application. <br /> Applications Will Be Processed When Su <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application' ma c o Usiness in the jurisdictional area of the/awn,Jo7agquinL cal � th District <br /> D Address <br /> Business N (DBA) <br /> Address <br /> Owner oZj <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> iBusiness Telephone No. p j <br /> Contractor Licence No. Title f S Date <br />�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 No. CAL. License Renewal No. <br /> Serial No. <br /> Gal.,Weights&Measures No. <br /> Capacity <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 R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test L cation <br /> q, NITATION PERMIT �� <br /> Job Addresst��ation _�'`-T'`lam Address <br /> Owner ❑ LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT _ <br /> 11 SEPTIC TANK ❑ CESSPOOL 11 NEW <br /> 1, REPAIR ❑ OTHER C.�Z)4 ,2J <br /> ❑ PERMANENT ❑ TEMPORARY <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site n <br /> No.of Units Equipment Storage/CleaningLocation(s) <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1,-June 39, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <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, and rul a regulati s of the n Joaquin Local Health istrict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 1&Received By July 31 <br /> Fee IS Due: ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July❑ REMIT <br /> 81LLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION pp <br /> PLUS <br /> PENALTY <br /> OTHER y I <br /> OTHER <br /> Receipt No. ermit No. I suance ate Mailed Delivered <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,,.. <br />