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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 is hereby m e trry o iness in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) OF Address �� <br /> z <br /> Q OwnerAddress.. <br /> ! <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Ib Emergency Telephone No. <br /> Contractor Licence No. `T <br /> L Applicants Name (Print) IM r Title Date `- <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMITIeREGISTRATION (FOR EACH VEHICLE) <br /> For July 1, . June 30, 19 I� Disposal Sites <br /> Description(Make/Yr., Color) �M i <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity i�. Gal., Weights &Measures No. A - c 1 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 4 <br /> No. of Vehicles Stored iM <br /> No. of Chemical Toilets Stored �M r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C:E. No. <br /> Test Location iM Test Date/Time <br /> t ' --4. ❑ SANITATION PERMIT :1 I f <br /> Job Address/Coca ion <br /> Owner N } Address <br /> R SEPTIC TANK El CESSPO,OL E ACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORIARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For•�July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of UnitsI1 Equipment Storage/Cleaning Location(s) <br /> 6. 13PACKAGE TREATMENT PLANT For July 1, -June 30,A19 C> <br /> F �. 'a <br /> iM - - <br /> Operator Name Where Certified <br /> c <br /> Plant Location - _._: <br /> Plant Capacity li �` `No:Units_Served 4 <br /> v <br /> M 7. 11LAUNDRY For July 1, -June-307.1.9 <br /> r ❑ More Than 1„000-5 Ft. <br /> - SIZE: ❑ Less Than 1,000 Sq. Ft:, q <br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that 1:hake ptepared'ttiis application and-tYiat'the'work will be done in accordance-with San Joaquin County 1 <br /> ordinances, state laws,"and rules a regu ions of the San Joaquin Local Health District <br /> APPLICANT'S SIGNATURE X <br /> JL FOR DEPARTMENT USE ONLY'` s ' <br /> t <br /> d By <br /> Fee Is Due, ❑ ANNUALLY 0 PER UNIT - ❑ PER SITE ❑ EACH ElJanuary 1 &Received By January 31 - ❑ July 1 &ReceiveREMMITuIy 31 <br /> I` BILLING REMITTANCE 8' AMOUNT DUE CHECKED <br /> M, ,• BASE. EXPLANATION DATE DATE REMITTED_ - AMOUNT. <br /> FEE <br /> LESS I� I <br /> PRORATION <br /> r! PLUS <br /> ­PENALTY' —" ✓ - <br /> i OTHER <br /> OTHER <br /> ' C9 ( 3 <br /> Received by Date Receipt No. Permit No.- lasuarice Date v Mailed Delivered _if/ <br /> APPLICANT—RETURN ALL COPIES TO:. 'ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 0 9• STOCKTON, `9526 �. <br /> I� - <br />