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Applications Will Be Processed When Subm <br /> itted ropeny <br /> LI �c`cv Vv <br /> ON <br /> y- (For Non-Transferable, Revocable, and Suspendable) SEpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ( -2-40 ro Z <br /> LIQUID WASTE Z 4 <br /> Applicati is hereby a to car on busineress <br /> ss in the jurisdictionaA�� the Sawn Joaq in L cal Heal istric ' <br /> OF Busines ame (DB Address <br /> aOwner <br /> 70 Firm Partners, Addresses and elephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Title Date� 10�?} -- <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7)and F 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) CAL. Uc:.nSe Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 =� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT }, <br /> Job Address/Location ' <br /> Address <br /> Owner ❑ <br /> ner ❑ PACKAGE PLANT <br /> ID/SEPTIC TANK El CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> El PERMANENT 1:1 TEMPORARY <br /> NEW 1:1 REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo, i r <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 regulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE L <br /> ❑ ❑ PER UNIT (� PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> Fee IS Due: ANNUALLY <br /> MIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> Received by Date <br /> Receipt No Permit No. I s anc Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZEL ON AVE.,P.D.Box 2009 STOCNTON,CA 8520 — <br />