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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application, i- <br /> APPLICATION <br /> , ) (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ( ENVIRONMENTAL HEALTH PERMIT <br /> II LIQUID WASTE <br /> Application i hereby made to carry on business in the j risdictional area of the San Joaquin Local Health District <br /> y Business Name BA) -„c� * Address IP-44 747 <br /> aOwner Address <br /> Firm Partners,Addresses and Telephone Numbers W <br /> aBusiness Telephone No. �� � Emergency Telephone No. fl' <br /> Contractor Licence No, a'z ` <br /> Applicants Name (Print) Title _. Date <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. .E.Name R.S.or R.C.E.No. <br /> Test L ation Test Date/Time <br /> 4. Ld SANITATION PERMIT2, <br /> Job Address/Lotion <br /> O�wnner Address <br /> I--I SEPTIC TANK CESSPOOL BLEACHING FIELD " L�EEPAGE PIT 0 PACKAGE PLAN <br /> PERMANENT ❑ TEMPORARY ANEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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 /> E 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 rules and re ations ,fQthe Joa_. in Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jarnw f`$Receivedkly J ry 1 [3 July 1 &Received By July 31 <br /> BILLING REMIT <br /> MITTANCE VE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE - DATE RE? ] AMOUNT <br /> _ ao <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issuande Date Mailed etivere I <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />