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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 f <br /> LIQUID WASTE <br /> Application is ere¢y m`a_¢e to carry on business in the jurisdictional area of the San Joaquin Local Health District} <br /> rn Business Name (DBA) ,L �L Address <br /> aOwner = Address - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. • ! Emergency Telephone No. µ <br /> � <br /> Contractor Licence No. <br /> L Applicants Name (Print) = Title, _ Date `x h <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, 1'9 - -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 <br /> 2. ❑ PUMPER YARD <br /> - I <br /> For July I, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑-PERCOLATION TEST'4 <br /> R.S. or R.C.E. Name I R.S. or R.C.E. No. Y t <br /> ` s <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT. t <br /> �- A A) <br /> Jab Address/Location u f <br /> Owner Address <br /> SEPTIC TANK �;CESSPbOL LEACHING FIELD ❑ SEE AGE PIT ❑ PACKAGE PLANT i J <br /> ❑ PERMANENT :Ca;.TEM06RARY_r ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July <br /> I Type Construction Disposal Site <br /> No. of Units — ? Equipment Storage/Cleaning Location(s) . <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June•30, 19 s <br /> Operator�Name ! _ ° Where Certified <br /> Plant Location _._.. <br /> Plant Capacity - •� No. Units Served # <br /> 7. ❑ LAUNDRY . For July ,,-;lune-30, 1.9 �3 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Thd1,000 Sq. Ft, <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 regulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 3 <br /> ` FOR DEPARTMENT;-USE-ONLY---- <br /> Fee <br /> EPARTMENT USEONLY^..._,...Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH S❑ January 1 &Received By'January 31_ ❑ July 1 &Received By July 31 <br /> - ## REMIT <br /> BASE E7CPLANAT{ON BILLING REMITTANCE $ i AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> d I i <br /> FEE <br /> LESS <br /> PRORATION " <br /> i i 1 <br /> PLUS <br /> PENALTY - I - €• s{..'. <br /> 1 OTHER <br /> OTHERi- <br /> .�._:...-+. - •• -----�.-...--.��_...�-.........�—..�_�-..mow...-^- ---... �_......_._.�� � �--..-.� -...-.,..... � v.�.... --- <br /> Received by Date Receipt Np.�,�.,,- .--Permit No- -- -- •�•�-•-Issux ce-Date Mailed Delivered 1. <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />