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ti 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 here y mad to carry on busi ess in the jurisdj $ional area of the San Joaquin Local Health Qist�rict { , <br /> F Business Nam DBA} �� Address �� <br /> z �" (Z Address <br /> a Owner Q j (,av"� <br /> J Firm Partners, Addresses and Tele hone Numbers ��' " C2 <br /> IL <br /> Business Telephone No. i 5 J Emer ency Telephone No. <br /> Contractor Licence'No. (Yl t2 h W <br /> w Title �E Date <br /> L Applicants Name (Print) Oj <br /> Please check Applicable Category (1-7)and Fill In the Required I formation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) j <br /> For July 1, June 30, 19 Disposal Sites , <br /> Description(Make/Yr., Color) r <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address - - <br /> 2. 11 PUMPER YARD _.. , + <br /> For July 1, i June 30, 19 ' t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored f, <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. NameR.& or R.C.E. No., w, <br /> Test Location Test Date/Time <br /> • F <br /> 4. ❑ SANITATION PERMIT �/� <br /> Job Address%Location X 1 <br /> avqe <br /> Owner Address <br /> ❑ SEPTIC TANK 13 CESSPOOL `LEACHING FIELD 11 SEEPAGE PIT 11 PACKAGE PLANT <br /> C1 PERMANENT ❑ TEMPORARY ElNEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site T� <br /> No. of Units Equipment Storage/Cleaning Location(s) a <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 's <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> t <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 /> { hereby certify ?hepared this application and-that-the the work will be done in accordance with San J In o nt <br /> ordinances, states and egulati ns S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE r. r AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> i PLUS <br /> rl PENALTY <br /> OTHER <br /> OTHER F <br /> �r3 �� <br /> � �3 I ��� ��3� � <br /> M Issua ce Da Mailed Uelivered <br /> Received by <br /> ` ate Receipt No. Permit No_ . <br /> r { . <br /> .�.,�.. �icca '� 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,?dA 95201 <br />