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Applications Will Be Processed When Submitted Properly Completed. BeSureTo51gn -1neAppncallvn. <br /> t APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE R <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> Business Name (DBA) <br /> aOwner T Address - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. j. t - " <br /> L Applicants Name (Print) Title - �d8 ; Date . d <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION..(F,OReEACH%VEHICLE), <br /> *0�.Disposal Sites" '� % <br /> For July 1, June 30, 19 p <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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.No. <br /> R.S. or R.C.E. Name ; <br /> Test Location <br /> Test Da /Time ! <br /> 4. ❑ SANITATION PERMIT I <br /> Job Address ocation <br />�• Owner � � Address , <br /> ' ' <br /> ❑ SEPTIC TANK CESSPOOL E] LEACHING FIELD Cr EEPAGE PIT ". PACKAGE PLANT r't <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW R EPAIR ❑ OTHER <br /> 5," ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> r No. of Units Equipment Storage/Cleaning Location(s) Y r <br /> 6. ❑ PACKAGE TREATMENT PLANT `For July 1, -..June 30, 19 i <br /> Operator Name _ �^"7 -- -Where Certified <br /> Plant Location <br /> f> <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 /> hereby certify that I have prepared this appli n and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, a d rut ' nd regulat' ns oft a San Joaqui oval Ith District. <br /> APPLICANT'S SIGNATURE X 6 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY _❑ PER UNIT ❑ PER SITE EIEACH 13January 1 &Received. January 31 [3 July 1 8 Received By July 31 <br /> 3 REMIT {t <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION , <br /> _ DATE DATE REMITTED- AMOUNT <br /> FEE S 's <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER - x <br /> OTHER F• r'` . <br /> l30 7 l ILP z <br /> Received by Date Receipt No. 'Permit No Issuance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />