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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Thi Application. _ <br /> APPLICATION v <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio s h r�lzy-made t c rry o si ss in the jurisdictional area of the San Joaquin L th District <br /> y Business Nag1 DBA) Address � ��f� �- <br /> aOwner x Address --�� — <br /> Firm Partners, Addresses and Telephone Num rs <br /> CL a Business Telephone No. Emergency Telephone No. 04 <br /> Contractor Licence No. <br /> L Applicants Name (Print) -Title Date 01 �orZ <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. Name R.S.or R.C.E. No. <br /> Test <br /> Loc Test Date/Time <br /> 4. ANITATiON PERMIT <br /> Job Address/Lo ion <br /> Owner Address <br /> EPTIC TANK a ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 {/J <br /> Type Construction Disposal Site S <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre is application and that the work will be done in accordance with San JoaquinCounty .� <br /> ordinances,state laws,and r s a regula° soft an Joaquin Local Health District. (� <br /> APPLICANT'S SIGNATURE X 4 e_ r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. rssuance 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 />