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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 i <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address 6 C�Hl eth Lane <br /> Same <br /> z Owner Address - <br /> C <br /> 7 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. — Emergency Telephone No. —4027 } <br /> X Contractor Licence No._l 3 36`79 <br /> Applicants Name (Print) -Title , Owner _ Date } <br /> Please check Applicable Category (1-7) and Fill in the Required Information �f} <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I " l <br /> 1 For July 1, June 30, 19 =- — :Disposal Sites <br /> ii <br /> Description(Make/Yr., Color) g <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. 0 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. ❑LSANITATION PERMIT <br /> ,. Job Address/Locatio% ` <br /> Owner ; Address <br /> ❑ SEPTIC TANK b C SSPOOL LJ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT: <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Site <br /> Type Construction Disposal <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 K <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 T <br /> SIZE: ,, ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Thereby certify that I have prepared this applicatPte <br /> d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d rul d r ations oan Joaquin Local ealt istrict. <br /> APPLICANTS SIGNATURE X _ <br /> E , y <br /> +�. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑^ANNUALLY" ❑ PER UNIT -11 PER SITE ❑ EACH 1:1 January 1 &Received y an [I July 1 &Received By July 31 <br /> t i REMIT <br /> ' BILLING REMITTANCE 4AMOlJNT DUE CHECKED <br /> } BASE EXPLANATION DATE DATE ARE NN <br /> AMOUNT <br /> d <br /> FEE <br /> LESS <br /> �^ i'PRORATION� <br /> PLUS <br /> PENALTY <br /> OTHER <br />�• OTHER. -1 .+� � <br /> i <br /> 1 , <br /> Received by Date Receipt No. Ferma No. - 15suanC ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH+,PERMIT/SERVICES 1601 E.HAZ N AYE.,P.O.Box 2009 - STOCKTON,CA 95201 - <br />