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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppncauon. i <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE i. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE k <br /> Appl icati is h eb— ade to ca onueshe}LJrisdictional area of th an quin Loca�j,Jiiea strict , sO <br /> Business Name (DBA) Address - ' �(J <br /> i Owner Address <br /> 4 <br /> n Firm Partners, Addresses and Tea hone ujn�ybers <br /> CL 6 I v Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. fQ <br /> LApplicants Name (Print) <br /> Title Date k <br /> Please check Applicable Category (1-7) and Fill in the Required Information - <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Y 7 <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. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time 1 <br /> Test ocation - <br /> i 4. SANITATION PER T O <br /> i <br /> Job Addr s/Loca A n <br /> Owner ..t Im Address _ <br /> SEPTIC T ❑ CES POOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 J <br /> f <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) q <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> ` Operator Name <br /> 1 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 /> I <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 ules and reg ations San J a in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> { Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRd By July 31 <br /> ! BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED AMOUNT <br /> FEE �. <1 <br /> LESS <br /> PRORATIONPLUS ' .A. <br /> PENALTY n v _ <br /> V� <br /> OTHER <br /> OTHER <br /> Received by Date Receipt Nn- .Permit No. -Issuance Date a d Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES - -1601 E.HAZELTON AVE.,P. =2009 STOCKTON,GA 95 <br />