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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 r <br /> Applicati n hereby made t c on business in the jurisdictional area of t4a.Sqn Joa uin Local ealth District <br /> wBusiness Name (DBA) Address �- <br /> z Owner ;<. Address <br /> Firm Partners, Addresses and T I p one Nfumbers <br /> IL Business Telephone No: r ��� C �� Emergency Telephone No. <br /> 3 Contractor Licence No. Li <br /> Applicants Name (Print) / Title 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, = June 30;-19' -- ..Disposal Sites••z- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No., CAL. License Renewal No. <br /> Capacity 1 Gal., Weights &Measures'No. I <br /> Equipment Parking Address ._ <br /> 2. ❑ PUMPER YARD r I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ' <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 Test Date/Time <br /> 4. SANITATION PERMIT e <br /> Job Address/ ovation r u� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL CK LEACHING FIELD SEEPAGE PIT ❑-PACKAGE PLANT } <br /> PERMANENT ❑ TEMPORARY ❑ NEWREPAIR, ❑ OTHER 1 �l <br /> -5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Y Disposal Site x <br /> No. of Units Equipment Storage/Cleaning Location(s) i n <br /> 6. ❑ PACKAGE TREATMENT PLANT For July`1, -June 30, 19 , + <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served f <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 L - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that) have prepared this application an at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations pf the an ojuin Local Health District_. , <br /> APPLICANT'S SIGNATURE'X <br /> 1 - FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER�UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receivetl By July 31 <br /> { BILLING REMITTANCE $ REMIT <br /> EXPLANATION - AMOUNT DUE CHECKED <br /> BASE <br /> ( 4 PATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I' <br /> PRORATION ^ <br /> PLUS <br /> PENALTY ell ' <br /> OTHER <br /> JAZY <br /> , I <br /> OTHER <br /> f <br /> r <br /> Received by - Date .Receipt No ermit No. Iss ante Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 852 <br /> i <br />