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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 /> Appl icati is her y ade to carry oLi b 'fne the juri ictional r f the Sph Joaquin Local Health tric <br /> F Business Nam (D A) <br /> i Owner A ress <br /> a <br /> J Firm Partners, ddresses and Telepho a mer <br /> 6. Business Telephone No. Emergency Telephone No.- <br /> Contractor Licence No. - <br /> �Applicants Name (Print) Title Date` <br /> Please check Applicable Category(1-7)and FIII in the Required Information l rt e, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)` ` <br /> For July 1, June 30, 19 - Disposal Sites ' -'t `'` � ; i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No.14 <br /> e r <br /> Capacity Gal., Weights BMeasures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD , , <br /> For July 1, EJune 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. orC.E. No.' <br /> Test Location � Test Date/Time?� <br /> 4.' ❑ SANITATION PERMIT t <br /> Job Add ress/Locatio <br /> Owner %4e7Address <br /> 19 SEPTI ANK CESSPOOL ❑ LEACHING FIELD C1 SEEPAGE PITS ❑ PACKAGE PLANT # <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ` OTHER s f <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t-s. i t � <br /> 4 <br /> Type Construction Disposal Site + <br /> No. of Units Equipment Storage/Cleaning Location(s) t ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June,30,-19 <br /> � � r <br /> Operator Name Where Certified r <br /> t <br /> Plant Location <br /> Plant Capacity k ' No. Units Sel- dIL V <br /> F F <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,5 ❑ More Than 1,000 Sq. Ft. t <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 and re tions of the San aquin Local Health District. ' <br /> 9 <br /> APPLICANT'S SIGNATURE X — 4 _ <br /> -_ -� - )# FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ .REMIT <br /> �.] ,ABASE :.EXPLANATION AMOUNT DUE CF�ECKED <br /> . - � DATE - OATE REMITTED .AMOUNT <br /> FEE `J'/ rL # � Aa Woke 5e 77 LESS <br /> PRORATIONPLUS .. <br /> /� �7 gypsy x <br /> PENALTY - p i 1>/ ���� ',/C.-G;/Gr4 tiwj <br /> OTHER 4 <br /> SOTHER-^-^ +Y <br /> Received by Date '._ Receipt No. Permit No Issuaried Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:-'%ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVI`.,P.O-eox 2009' STOCKTON,CA 95201 ] <br />