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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> F ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is Eby adt .arty o busi ss in the jurisdiC 'onal area of the San Joaquin Local Health 1spt�ict / 1 <br /> Business Name (DBA) v � �" 'z^Address c✓1 r c�r %oc l 04 <br /> z Owner _'a a-. a Address <br /> 9 <br /> J Firm Partners, Addresses and Telephone Numbers .� <br /> a Business Telephone No. 3' S 3�^Z Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) v Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required information ' 7 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites a , <br /> Description(Make/Yr., Color) f <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. y <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 j <br /> 4 No. of Vehicles Stored <br /> r No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Ij <br /> R.S. or R.C.E. Name R.S:or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. "KSANiTATION PERMIT <br /> Job Address/L tion <br /> Owner <br /> R l Address <br /> 19 SEPTIC TANK ❑ CES POOL LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> -0 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> I 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 /> ! No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 3, <br /> SIZE: 13 Less Than 1,000 Sq. Ft., 13More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ._. . .! <br /> it ». <br /> € <br /> I hereby certify that I have prepared this application and that the work will be done in accordance w�th San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X (^ <br /> FOR DEPARTMENT USE ONLY i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EI EACH ❑ January 1 &Received By January 31 ❑ July t &Received By Juiy 31 ' <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED r, <br /> BASE EXPLANATION DATE _ DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS li <br /> PENALTY <br /> OTHER <br /> OTHER II <br /> 2 I! <br /> Received by Date Receipt No Permit o- Iss ante ate Mailed Delivered <br /> ., <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT N,CA 952 <br />