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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h eby made to carry on business in the juri fictional area of the San Joaquin Local Health Dist i <br /> rBusiness Name (DBA) G Address �� ���-i' � 7 <br /> z Owner Address <br /> 9 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) C Title �/t_r Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information {� <br /> 1. ❑ PUMPER VEHICLE PERMIT:REGISTRATION (FOR EACH VEHICLE) <br /> For July 1' Ju e 30;19 Disposal Sites <br /> Description(Make/Yr., Color)- ' <br /> Serial No. s _ CAL. License No. CAL. License Renewal No. <br /> %Gal., Weights & Measures No. <br /> Equipment Parking..Address <br /> 2. ❑ PUMPERYARDIs <br /> For July 1� JuA9 <br /> No. of Vehicles Stored A <br /> No. of Chemical Toilets Stored ) <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location I Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job dress/Location <br /> O er J n ' Address F Rd, <br /> TANK ❑ CESSPOOL ULEACHING FIELD ❑PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW _,REPAIR ❑ OTHER _1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction I Disposal Site I = <br /> t 1, <br /> Na. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 I <br /> Operator Name t Where Certified <br /> Plant Location �~ I <br /> Plant Capacity LOOP,— No.Units Served,r <br /> 7. ❑ LAUNDRY For July 1, -June 30,99 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑'More Than 1,000 Sq. Ft. r�� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. '4 <br /> I hereby certify that I have prepaL'this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule lations cf the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> it <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ju!y 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> [« c AMOUNT <br /> FEE L45 444 S <br /> LESS <br /> PRORATION <br /> f <br /> PLUS <br /> PENALTY A <br /> f <br /> OTHER <br /> OTHER i <br /> t <br /> Received by Date Receipt No. Permit No. Iss nce Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAM 10—AV .O.Box 2009 STOCKTON,CA 95201 <br />