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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) ! SEPTAGE <br /> +� \\ ENVIRONMENTAL HEALTH PERMIT <br /> "\ LIQUID WASTE <br /> Application is her by adetarry on bu iness in the jurisdictional a ea of the San Joaquin Local Health District <br /> UF) Busin ss Name (DBA) :� - dress <br /> z Owner Address Qa Gr <br /> J Firm Partners, Addre ses and Telephone Numbers <br /> aBusiness Telephone No. -,-zEmergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) w' Title Date le " �-; 7 <br /> Please check Applicable Category(1-7)and Fill in the Re ired information __3 <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location �� o d <br /> Owner Address <br /> ASEPTIC TANK ❑ CESSPOOL �CEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ASE <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site pd <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 prepared this application and that the work will be done in accordance,with San Joaquin County <br /> ordinances, state laws, and_rules an regulati of the n 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> BATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> �3 UA5 <br /> Received by Date Receipt No. Permit No. Ibsuanct Date Mailed Del vered <br /> APPLICANT—RETURN ALL COPIES TO:: ;-ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />