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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 /> Application is my made to carN on busing in the ju 'sdictional area of the Sano qul ocal Health District <br /> yBusiness Name (DB Ad ressL� ��7 <br /> z Owner ddress <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a -Telephone No. —d�L,(�r'!d�' Emergency Telephone No. <br /> Contractor Licence No. �Z <br /> a9 <br /> Applicants Name (Print) Title tGL" Date <br /> Please check Applicable Category (1-7) and Fill in the Require nformatlon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V , <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. Name R.S. or R.C.E. No. <br /> Test Lation Test Date/Time <br /> 4. L+J SANITATION PERMIT <br /> Job Address Location <br /> ,Ow er �� Address '° <br /> f SEPTIC TANK ❑ CESSPOOL �EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT � <br /> El PERMANENT 1:1 TEMPORARY L7 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 7, <br /> No. of Units Equipment Storage/Cleaning Location(s) �1 <br /> G. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified LI <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., 13 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 regulations o th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> a �S 4S <br /> FEE � <br /> LESS <br /> PRORATION I Gk <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> n I <br /> Received by Date Receipt No. Permit No. lisuance'Datel Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> F'eal � �16 -�� <br />