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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 hereby made to c ry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Lo Business Name (DBA) Address Z+d <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a, Business Telephone No. Emergency Telephone No. <br /> a Contractor Licence No. <br /> Applicants Name (Print) �T Title Date 10-144 J <br /> Please check Applicable Category (1-7) and Fill in the Required Information ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r�y <br /> For July 1, __ June 30, 19 Disposal Sites �f l <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 .4 <br /> No. of Vehicles Stored r , <br /> No. of Chemical Toilets Stored <br /> 3. ❑-PERCOLATION TEST <br /> �R.S!or R.C.E. Names R.S. or R.C.E. Na. <br /> Tt Location Test Date/Time <br /> 47W-SANITATION PERMIT <br /> Job Address/Location <br /> ner Address <br /> O <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGt PIT ❑ PACKAGE PLANT <br /> APERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 co <br /> Type Construction Disposal Site <br /> No. of Units __ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Tl <br /> Operator Name Where Certified U <br /> Plant Location <br /> Plant Capacity No. Units Served A <br /> s .� <br /> 7. 11 LAUNDRY For:July 1, -June 30, 19 � � .r , � FAli <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000-5q`Ft:{ r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home olunerarl7oensasr ager natclr�r.�rr;rt�.lhs ic1'e:v�r+g:"I rerlifYpPrferm nreol th.wcrkicr; c!th+s fermi;i issuad,l shall nut employ any der. <br /> I❑SUC;1 mann.,:15{]�t',Crr€ �I't ri i V C' �Qie c:;%;;t1r91 E �.: i%:i:G: .-., <br /> Contractor's t:€ring or cub oo znmi _:gfN7119ra cert ii :; 3S�vripl;; i Co,�ii,l:atiirl'the perfLanance of the work for vihich this permit is issued.t si;all <br /> employ persons subject tJ morkmar:'s cun,pc:lsation I2r,5 si Caliiumia" <br /> w I hereby-certify that'I haverepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, le and regulatio f the San J q n Local H th istriet. <br /> APPLICANT'S SIGNATURE. <br /> FOR DEPARTMENT USE ONLY s <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 - <br /> BILLING REMITTANCE v $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED 7 <br /> l AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. I suanc -Date Mailed Delivered y <br /> APPLICANT=RETI]RN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005 STOCKTON,CA 852D1 <br /> 1 <br />