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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1' <br /> APPLICATION ; <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic tion is hereby made to c on busi ess int e j risdictional area of San Joaquin L cal He Ith District <br /> WF Business Name {DBA} — '-` Address S .�� <br /> i Owner Address <br /> a <br /> J Firm Partners, AddresseAaTelephone Num ers4Business Telephone NoEmergency Telephone No. <br /> Contractor Licence No.Applicants Name (PrintTitle DateLy <br /> Please check Applicable Category (1-7)and Fill in the Required Information } <br /> 1. ❑ PUMPER VEHICLE PER REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) « <br /> Serial No. CAL. License No. CAL. Lircnse Renewal No. <br /> F <br /> Capacity Gal.-,,Weights & Measures No=-'­ <br /> Equipment <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 <br /> R.S. or R.C.E. NaM67 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PE <br /> Job Addre /Location - L�V► _ - - <br /> Owner _ 4 S y ��- !Address <br /> 11SEPTIC TANK ❑ CESSPOOL }LEACHING FIELD SCEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY /❑ NEW '. REPAIR ❑ OTHER <br /> (.�., <br /> 5.' 11 CHEMICAL TOILETS For July 1, -June 30, 19 -� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) _ t <br /> 6. 'Cl PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ <br /> 'Operator Name Where Certified a S <br /> Plant Location <br /> --,,_Plant <br /> No. Units Served <br /> 'Plant Capacity <br /> _ r <br /> 7.'-] LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than-1.000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> �!f <br /> hereby cert.y tha have prepay this apQlica ion and that the work will be done in accordance with San Joaquin County <br /> -� ordinances, st to law d rule an reg ti ns the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE # <br /> r <br /> �� 1 <br /> FOR DEPARTMENT-USE ONLY <br /> i Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑,.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE HATE REMITTED AMOUNT <br /> a # <br /> FEE "— <br /> S <br /> I <br /> LESS 1 ! <br /> PRORATION <br /> PLUS <br /> PENALTY 42 <br /> OTHER <br /> OTHER <br />.ry <br /> LfR.ceived by -- Date cel o. Permit No. Is uanc Dat Mailed. Delivered <br /> r <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTDN AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />