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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. , <br /> APPLICATION <br /> F_ t14--k Y u R (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Y <br /> Ap-plication_ZhereLby mad to CW on b iness i the juri ictional area of the Sa aq .W Local Health District <br /> Business Name (D ) Address 2 <br /> r z Owner Address. <br /> i a <br /> Firm Partners, Addresses and Tel hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. 2-7— <br /> fDate <br /> �Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill in the Required Into anon- t] <br /> L° 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 .f <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 /> ! TesttLation Test Date/Time <br /> E. <br /> 4. SANITATION PERMIT <br /> Job Addre s/ ocation <br /> G�O,wn Address J <br /> TANK ❑ CESSPOOL ,�, L CHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT <br /> r EY PERMANENT ❑ TEMPORARY n NEW E?F�'EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 .. <br /> t Type Construction Disposal Site <br /> f 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 /> r <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 a regulations of Joaquin Local Health District. <br /> EE APPLICANT'S SIGNATURE X <br /> r <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By J ary 1 July 1 &Receiv July 31 <br /> MIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE 1 CHECKED <br /> DATE DATE REMi 1) V AMOUNT. <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> , Received by --"` Date Receipt No. - Permit No. k Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1681 E.HAZELTON AVE.,P.O.Bo=2009. STOCKTON,CA 95201 <br />