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y .. +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 J <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Tel phone Numbers <br /> CL Business Telephone No, <br /> Emergency Telephone No. <br /> -J Contractor Licence No. Date <br /> LApplicants Name (Print) y Title <br /> Please check Applicable Category (1-7)and Fill In a 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) CAL. License Renewal No. <br /> Serial No. <br /> GAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> I <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 a <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 PERMIT <br /> Job Address/Location .M <br /> .+H �.+�.' ,4 Address— <br /> Owner4 i <br /> rPERMANENT <br /> EPTIC TANK ❑ CESSPOOL I�CEACHING FIELD ❑ SEEPAGE PIT �P4CKAGE PLANT 1 ; <br /> ❑ TEMPORARY ❑ NEW ❑ REPAIR .�'` ❑ <br /> OTHER "~ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ rs <br /> Type Construction Disposal"Site <br /> No. of Units Equipment Storage/Cleaning.Lodation(s) <br /> 6. ❑ .PACKAGE TREATMENT PLANT For July-1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity . <br /> 7. ❑ LAUNDRY For.July 1, -'-J u ne 30, 19 <br /> SIZE! ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> r ❑ 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 r gulations of the San Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br /> Q <br /> r <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑-ANNUALLY -❑ PER UNIT ❑ PER SITE.. ❑ EACH ❑ January 1 8 Receivve"d-By,Janu�r_y 31 ❑"Jul'y 1 &Received By July 31 <br /> _- - REMIT <br /> BILLING REMITTANCEtr' CHECKED <br /> _ <br /> BASE EXPLANATION - AMOUNT DUE <br /> � DATE DA/TE/�.�i REMITTED- AMOUNT <br /> FEE <br /> LESS <br /> 4 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �673 5 7 <br /> Received by Date Receipt No. Permit No I 'suan ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA95201 <br />