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Applications Will Be Processes Wnen Suomlttes Properly compietea. Be tiure t o tiIgn i ne 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 the San Joaquin Local Health District <br /> rn Businesme ( BA) <br /> Owner 1 1 Yt �/ Address ddress t <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0.a Business Telephone No. Emergency Telephone No. 'i-- <br /> Contractor Licence No. <br /> L Applicants Name (Print) a +� ` Title kp f adao 0- Date i <br /> Please check Applicable Category(1-7)and Fill in the Required Information ILA <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. <br /> 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 Location Test Date/Time <br /> 4. M SANITATION PERMIT <br /> Job Addr s/location 5-9 <br /> on / 'S, \ <br /> Owner t ( ," <br /> Address 6 45 h- <br /> 13 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER CJl <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Clef riinb-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- J <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, rules n regu Ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <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 /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS r�/ <br /> PENALTY 77 <br /> OTHER <br /> OTHER <br /> Received by Date I Receipt No. Permit No. Issuance DateMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />