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x Applications Will Be Processed When Submitted Properly Completed. taeSure Io algn 1rre^NN <br /> APPLICATION <br /> (For Non-Transierable Revocable,gand Suspendable) SEPTAGE <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic i is here y carry on business in the jurisdictional area of t San J o a ui Local at D�S�ricts <br /> ` Address (�•J <br /> Business Name (DBA) <br /> z Owner Address _ <br /> a <br /> Firm Partners, Addresse4and pEmergency Telephone,Na Business Telephone NoContractor Licence NoDaieTitle <br /> L Applicants Name (Print ` <br /> Please check Applicable Category (1-7) and Flll,in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - -- . <br /> For July V June 30, 19 - _:=Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. V <br /> Serial No. CAL. License No. <br /> w � <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 T <br /> 3. ❑ PERCOLATION TEST ., R.S. or R.C.E. No. <br /> .R.S.or R.C.E. Name ` - r - <br /> 4 Test Date/Time ; <br /> i Test Location ; .• -�, <br /> 4. SANITATION PER IT <br /> Job Addre /Location _ ' <br /> I Address Y <br /> Owner ❑ PACKAGE PLANT <br />( ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT <br /> r11OTHER <br /> 'PERMANENT ` REPAIR❑ TEMPORARY ❑ NEW Y <br /> 5. ❑ CHEMICAL TOILETS For July 1,3 June 30, 19 E ° <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT.PLANT For July 1, -June 30, 19 0 <br /> g i -r. . <br /> { Where Certified <br /> Operator Name ` <br /> Plant Location_ <br /> Plant Capacity No. Units Served <br /> , , <br /> 7. 11 LAUNDRY < For.July.1;-";June 30;-19 w <br /> SIZE: ❑. Less Than 1,000 Sql Ft., ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> c <br /> I hereby certify that'l have prepared this applica' and'that the work will be done in accordance With San Joaquin County' <br /> ordinances, state laws, and rules ul :on of e n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE — 1re� <br /> L2 zt <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due-. ❑ ANNUALLY ., ❑ PER UNIT_ ❑ PER SITE ❑ EACH ❑ January 1 &Received Ry;January 31 July 1 8 Receiv EB�ITu4y 31 <br /> BASE 1.EXPLANATION BILLING REMITTAiNCE t '$ AMOUNT DUE CHECKED <br /> B r DATE ;^ f DATE 4REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS { /Z� <br /> PENALTY ' <br /> OTHER <br /> OTHER.. - I <br /> Receipt No. Permit No - Issuan Date Mailed Delivered <br /> Received by - Date t A 95201 <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2609 STOCKTON,C <br />