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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> `i APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> II <br /> ENVIRONMENTAL HEALTH PERMIT LIQUID WASTE <br /> Application is hereby made to carry on business n the j ri ictio_nal area of the San Joa uin Local Wealth istrict <br /> y Business Name (DBA) Address t <br /> z Owner Address i <br /> a <br /> Firm Partners, Addresses and,Tej hone Numbers <br /> C6 <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title Date- <br /> Please check Applicable Category(1-7)and Fill^in the Required information _ ! <br /> -1 1.` ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 ajy- Disposal Sites ' <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> 'Capacity,— '"" ' . Gai`'Weights&-Measures No.-- -��- <br /> =- '- - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored_ <br /> Stored , .- 77i-2-7_7 i <br /> No. of Chemical Toilets <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name f R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERI(IIIT� r <br /> s <br /> Job Address/Locatj _n � <br /> Owner1� Address <br /> 11 SEPTIC TANK 11 CESSPOOL 4 13LEACHING FIELD SEEPAGE PIT ❑ PACKAGE` PLANT + i <br /> ❑ PERMANENT ❑ TEMPORARY ;` 1:1 NEW, I REPAIR <br /> 13 OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1,--'June 30,19 <br /> .Type Construction n rr Disposal Site <br /> No. of Units Equipmerit:Storage/Cleaning Location(s) <br /> i 1 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.1, -'June 30-16'---- [ <br /> Operator Name Where Certified <br /> I ()j. <br /> Plant Location <br /> Plant Capacity } '( No. Units Served ( U,) <br /> 't <br /> 7. ❑ LAUNDRY For July i, -June 3071-9 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑.'Mor'e Than 1,000 Sg. Ft. � �� �- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t +` <br /> I hereby certify that ve (prepared tis applicatio nd that the work will be done in acc&rdance wiih San ,loaquin County <br /> ordinances, state ws, a ules nd r f I Sa �JoaL��n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> _ <br /> ^ »:� FOR.DEPARTMENT'USE ONLY .,. <br /> Fee Is Dile: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 1 ❑ July 1 &Received By Jury 31 <br /> REMIT I <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> I DATE DATE REMITTED AMOUNT i <br /> FEE <br /> LESS } - <br /> PRORATION <br /> PLUS -. y <br /> PENALTY <br /> OTHER <br /> u i <br /> OTHER }..r..a.....,:. ..._.,........+�--�.-.-:.... - .......,.�..�....,. r. ,. -- <br /> Received by Dale I; Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PEAmiTiSERVICES `1601 E.HAZELTON AVE.,P.O.Box.2009 STOCKTON,CA 95201 <br />