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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 i Ireb made to rry on business in the jurisdictional area of the San Joaquin LocaLHealth District <br /> ,�Business Name BA) Address d, }r ��� �R)77— <br /> aOwner Address <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �r G� -... .._ Emergency Telephone No. <br /> Contractor Licence No. <br /> r4 IF <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information s� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) R 5S <br /> For July 1, June 30, 19 Disposal Sites - r <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 I <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 -No,of Vehicles Stored ' <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> R.S. or R.C.E. Name r ' R.S.or R.C.E. No. <br /> Tes Location `Test Date/Time y <br /> 4. ANITATION PERMIT <br /> Job Address/Location <br /> O 'Address �- <br /> EPTIC TANK ❑ CESSPOOL I EACHING FIELD )X@EEPAGE PIT ❑ PACKAGE PLANT, <br /> A,GERMANENT ❑ TEMPORARY Mct+EW I ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - ) -Disposal Site <br /> No. of Units Equipment'Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1',Oit June 30, 19 <br /> Operator Name Where Certified t <br /> Plant Location <br /> Plant Capacity _ 3= No. Units Served y <br /> 7. ❑ LAUNDRY For July 1,'-June 30 19 - —- --•+-�-- i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.1 ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that'l-have prep ed this app cation and that the work'will be done in accordance with San Joaquin County <br /> ordinances, state laws,,and r es d regula ns of the an Joaquin Local Health District. € , <br /> APPLICANT'S SIGNATURE X <br /> �. <br /> +•+�,� FOR DEPARTMENT USE ONLY <br /> k. <br /> Fee Is-Due: ❑ ANNUALLY __❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 8,Received By January 31 ❑ July 1 8,Received By July 31 ' <br /> wrreF <br /> t BILLING REMITTANCE $ REMIT <br /> BASE 'EXPLANATION AMOUNT DUE CHECKED <br /> {,. # DATE -F DATE, REMITTED AMOUNT <br /> FEE <br /> LESS Q <br /> PRORATION;: _I • i <br /> PLUS • + <br /> -PENALTY <br /> OTHER t <br /> OTHER <br /> Received by Date -Receipt No. - Permit No. Iss ante[Date' Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201' - <br />