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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGF <br /> -� ENVIRONMENTAL HEALTH_ PERMIT ' <br /> LIQUID WASTE <br /> Application her b 'dip to car n business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name(DBA) Address <br /> t'f' �h Address <br /> aOwner r Address 4 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL /Business Telephone No. 7�6_ Emergency Telephone No. �l <br /> Contractor Licence No. . y " <br /> L ApplicantsTiile i Date <br /> "F <br /> Please check Applicable Category(1-7)-and Fill in the Required Information ,. PAM k 4L . <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d <br /> For July 1, June 30,, 19'- - Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal:, Weights & Measures No. r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD < }. .r.. '� ... . <br /> For July 1, June 30, 19 t <br /> No. of Vehicles Stored ' <br /> 'No. of Chemical Toilets Stored <br /> 3. ❑ PE COLATION TEST <br /> R.S. or R.C.E. Name 3 ft.S. or R.C.E. No. F <br /> Test Location ' f.v Test Date/Time. <br /> 4. ❑ SANITATION PERMIT r <br /> Job Address/Location <br /> O�wn�r d T/— Address- <br /> SEPTIC <br /> ddress -� -- <br /> L SEPTIC TANK' ❑ CESSPOOL ING FIELb E] 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY RNEW ❑ REPAIR OTHER.: f <br /> �. <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction -- s. Disposal Site--- ----r---�- ��--�- - s-• ____ __ <br /> No. of Units -Equipment Storage/Cleaning'Location(s) �b F <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 .f <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> Plant Capacity ` No. Units.Served i <br /> i 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 SST ❑ More Than 1,000 Sq. Ft. <br /> Il ❑ DRY CLEANING, Chemicalspsed/Amount/Mo. T <br /> I hereby certify that 1'have prepared thi application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and gulati ns of the.San Joaquin Local Health District. !' <br /> � <br /> f. <br /> APPLICANT'S SIGNATURE X !� gL' �•�� ��'�' ° �r�� <br /> FOR DEPARTMENT USE ONLY t - <br /> Feels Due: ❑ ANNUALLY ❑ PERUNIT:. ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 + j �i "- REMIT <br /> _• BILLING REMITTANCE $ <br /> 3h BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> `FEE -4S <br /> `. <br /> LESS <br /> PRORATION <br /> PLUS <br /> j .. <br /> •PENAIr <br /> L-T-Y'. <br /> OTHER. # <br /> V_ <br />.. ,. "OTHER <br /> i <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.Box 2009 STOCKTON,GA 95201 <br /> F <br />