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Applications Will Be Processed When Submitted Properly CompletedF Be Sure To Sign The Application. <br /> APPLICATION <br /> Y-L t (For Non-Transferable,Revocable,and Suspendabie) SEPTAGE <br /> ( ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's h reby m de•to rry on business in the jurisdictional area of the Sa Joaqu Local a It (strict <br /> OF Business Name ( BA r Address �� ��!� <br /> aOwner �__ �� Address <br /> Firm Partners, Addresses and T P)v Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title �_-; {� Date (ez� " <br /> Please check Applicable Category(1-7)and Fill in the Required Information " <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) 'C <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 L ation Test Date/Time <br /> 4. SANITATION PERMIT 3 <br /> Job Address/Loc�ltion <br /> Owner C t'� 2 (�FYI Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL WLEACHINGFIEL'D [!?REPAIR OTHER PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW L`?REPAIR OTHER <br /> 5. ❑ CHtMICAL TOILETS. For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> 4o. of Units Equipment Storage/Cleaning Loca,tion(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 +�-+ <br /> Operator Name `° Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> ` 7. ❑ LAUNDRY For July 1, -Jppe 30, 19 - <br /> SIZE: 0 Less Than 1,000 Sq.-Ft„ ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <br /> z <br /> I hereby certify that) have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws;and rules and regul 'ons of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X. <br /> FOR DEPARTMENT USE ONLY <br /> Fee.ls Due:❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ,'1❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4s- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. 1 uanc D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. AZELTON AVE. P.O.Box 2009 STOCKTON,CA 952 <br />