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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The+App(ib ation.;, <br /> APPLICATION <br /> 1`R.�•a.." R •. + L <br /> (For Non-Transterable,'Revocable,band Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTHTERMIT), <br /> LIQUID WASTE C-i <br /> Application is her y made to carry on business in the jurisdictional area of the an Jo quin Local Health District a �, <br /> rn Business Name (DBA) � S 4Address -p � <br /> z OwnerAddress <br /> a .- - <br /> J Firm Partners, Addresses and Telephone NumbersIL , <br /> Business Telephone No. ,• � p 07 _Emergency Telephone No. -- <br /> Contractor Licence No. <br /> Applicants Name (Print) k :Title��TI ��- Date <br /> Please check Applicable Category (1-7) and Fill In the Required.Information , �r r� :.,� ;.r }Fj_ _. " d <br /> 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, 19T <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> i 3. ❑ PERCOLATION TEST 4 • .fit 1' )';. .,. <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location ( Nest Date/Time <br /> 4. ®SANITATION PERMIT <br /> Job Address/Location p <br /> Owner 1 A Address_ <br />+ ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ®SEEPAGE PIT ❑ PACKAGE PLANT , <br /> B-VERMANENT ❑ TEMPORARY ❑ NEW„ , B REPAIR ❑ OTHER � <br /> 5. ❑ CHEMICAL TOILETS For July 1,.-`:lune 30,,:19 ) <br /> e ` <br /> Type Construction Site <br /> � 1 Disposal . <br /> No. of Units ! Equipment Storage%Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> _fes <br /> Operator Name I- Where Certified" <br /> - <br /> R. 'Plant Location i � <br /> Plant Capacity . t` t No. Units Served <br /> 7. '11 LAUNDRY For July 1 r`June 30, 1.9 tIt t-� ` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑!More Than 1,000 Sq.(Ft. �: t <br /> El DAY CLEANING, Chemicals'Used/Amount/1tiAo. ' <br /> I hereby certify that-1 have prepared this application nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d uIesTan'd r ulatibns o San J in L cal Health District. <br /> APPLICANT'S SIGNATURE X -'' <br /> i .,.� .FOR.DEPARTMENT.:USE.ONLY� <br /> Fee Isue: ❑ ANNUALLY 1 El PER'UNIT ❑ PER SITE ❑ EACH =r❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> . _ .. _. REMIT <br /> BILLING REMkTTA'NCE a '� AMOUNT DUE CHECKED <br /> BASE EXPLANATION f <br /> 1 t DATE DATE REMITTED rAMOUNT <br /> FEES! <br /> LESS fr - <br /> PRORATION 1 +».?-• �=-� -- -- <br /> PLUS I t <br /> PENALTY <br /> OTHER; t. .i. _ V _ •i�t,-.�' .. - <br /> ' <br /> OTHER ... l <br /> ..�Received by Date., Receipt No. 4 Permit No. : � Issuance,Da eT Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL STOCKTON,CA 95201 <br /> HEALTH-PER MITISERVICES,. 1601 E..HAZE4TON,AVE.,P.O.Sox 2009 <br /> 4 <br />