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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 h reby ma a to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Nart1e (DBA) 041 �5 Address . �fc/wm <br /> zOwner <br /> a -7 C Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. <br /> Business Telephone No. Emergency Telephone No. ,� ..- <br /> Contractor Licence No. <br /> Applicants Name (Print) • Title Z/-,4A Date 1/'4V ; <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, 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. <br /> Equipment Parking Address €. f ''� s--� P ;Z f <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored — -^�---- <br /> No.-of.Chem ical-Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.Or R.C.E. Name ~` R.S. or"R.C.E. No.a <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT j �~ <br /> Job Address/Location / Q S', <br /> Owner <br /> ril�sys � •• <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> C7 PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER C } <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r a <br /> No. of Units Equipment Storage/Cleaning Location(s) { <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> w <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served '' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 17 Less Than 1,000 Sq.'Ft.' ❑"More'Than 1,000'Sq. Ft. W , <br /> ❑ 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 reg`ufatio of th -San Joaquin Local Health District.'„ , <br /> APPLICANT'S SIGNATURE X t <br /> y �J <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY _ _❑ PER UNIT ❑ PER SITE ❑ EACH ❑.January 1 &Received By.January_31—^-❑g July 1 &Received By Juky 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ' ,t <br /> PRORATION <br /> PLUS , <br /> PENALTY <br /> Y t \ <br /> OTHER <br /> i <br /> OTHER <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:2005 STOCKTON.CA 95201 <br />