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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TneApplication. <br /> I1k APPLICATION <br /> \,(For Non-Transferable, Revocable,'and Suspendable) '" w� SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her�j�'made to carryon business in the jurisdictional area of-the San Joaquin Local Health District <br /> „r, Business Name (DBA) Address <br /> z Owner Address - <br /> Firm Partners, Addresses and Telephone Numbers ' <br /> CL <br /> Business Telephone No. _J / 0 Emergency Telephone No. /•Cl <br /> -i Contractor Licence No. <br /> L Applicants Name(Print) 4 Title F 01jner — Date— <br /> 0 1 f <br /> Please check Applicable Category (1-7)-and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE), ) <br /> ` � .• <br /> For July 1, = June 30, 19 Disposal Sites <br /> t <br /> Description(Make/Yr., Color) ^� <br /> Serial No. CAL. License No. CAL. License Renewal No. . <br /> Capacity Gal.,Weights & Measures No. <br /> r <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. Namea, t 1 R.S. or R.C.E. No. <br /> -Test Location °f -} Test Date/Time <br /> 4. ❑ SANITATION PERMI+ 'f <br /> Job Address/Location t 1 <br /> i <br /> Ownert Address <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT f <br /> 11PERMANENT ❑ TEMPORARY ❑ NEW REPAIR 13 OTHER <br /> 5. ❑ CHEMtCAL'TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> 4 No" of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator NameWhere'Certified <br /> s <br /> Plant Location I 4 f <br /> Plant Capacity A No. Units Served <br /> 7. '❑ LAUNDRY For July 1, -June 30, 19 s <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than.1,000 Sq.-Ft_ s� <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 3 <br /> Ordinances, state laws, and rule •regulatio - f the San Joaqui L I Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> { <br /> `# s <br /> FOR DEPARTMENT USE ONLY ,{ <br /> Fee Is Due: 11 ANNUALLY ',_❑�PER UNIT; 11 PER SITE ❑ EACH ❑ January.l,&Received By January 31 ❑ July 1 &R ceivetl 8y July 31 <br /> - t --- _ - •REMIT <br /> BILLING REMITTANCE , $ AMOUNT QUE .CHECKED <br /> BASE EXPLANATION <br /> - DATE - DATE ,REMfTTEO AWIOUNT <br /> ri <br /> FEE <br /> LESS <br /> PRORATION "� ! <br /> PLUS .t f <br /> PENALTY -4 <br /> PENALTY t • <br /> OTHER {; <br /> OTHER <br /> mI <br /> al <br /> Issua ce ate Mailed Delivered i <br /> Received,by Date d Receipt-No. Permit > <br /> APPLICANT—RETURN ALL COPIES Td: ENVIRONMENTAL HEALTH PERM&SERVICES 1601 E.HAZELT VE.,P.O.Box 2009 STOCKTON,CA 9520 <br />