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PN <br /> ed 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 /> Ap_pI icatiotla hereb m de to carrgn b siness in the I�rjs�iictional area of the an Joaquin al Health District <br /> rBusiness (DBA) R I foe. Acki4n- '�Ct Address � � Ave, <br /> Q Owner F f&I C�R�'��� Address <br /> Firm Partners, Addresses and Telephone Numbers 8 a <br /> a. Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence Na Date <br /> L Applicants Name (Print) Title W <br /> Please check Applicable Category(1-7)and Fill in the Required Information <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. Lic Ise Renewal Na_ <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 <br /> Test Location <br /> 4. ❑ SANITATION PER !I , ,, _ n/0z P � �y <br /> Job Addre � /� �� �ocation %/ <br /> Owner eA0V s Address <br /> IT SEPTIC TANK ❑ CESSPOOL Q LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 /,�©� 6�9L �Cp yyG yAN� _ 7©r h�'�� /we <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) (J 11 <br /> 6. 1:1PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No.Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <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 of th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />