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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> j APPLICATION <br /> (For Non-Translerable, Revocable;and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL. HEALTH'PERMIT <br /> LIQUID WASTE <br /> Application i rrlade o carry n siness in the jurisdictional area of the San Joaquin Local Health District <br /> F'Business Name DBA IS� ��qAt Address <br /> aOwner_ Address w <br /> Firm Partners, Addresses and Tele hone N upi•bers - <br /> a Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 4l Date <br /> Please check Applicable Category,(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) wk <br /> For July 1, June 30, 19 :I Disposal Sites - - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity_ i1 Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 �yw +• <br /> No. of Vehicles Stored �M1 <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST N. ' D' <br /> R.S. or R.C.E:sNo. �''�t . oQ <br /> R.S. or R.C.E. Name -�- <br /> Test ocation - �� Test Date/Time z t` <br /> 4. PSANITATION PERMIT <br /> Job Ad ss/L cati n �_ _ "• <br /> Owner w Address -1 <br /> ❑ SE IC TANK ❑ ESSPOOL LEACHING FIELD ❑•SEEPAGE PIT- ❑ P CKAGE PLAN <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR $OTHER tf5e f 0�l� 4��. *ff2 <br /> S. ❑ CHEMICAL TOILETS For July 1,, -June 30, ig # <br /> Type Construction Disposal Site y <br /> No. of UnitsEquipment Storage/Cleaning.Location(s) r 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July i ',June 30, 19 <br /> Operator Name ( Where Certified <br /> Plant Location f # � <br /> Plant Capacity e + No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. w <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ) t <br /> -,a <br /> I hereby certify that I have prepared this application and !hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules and r ulatiohs a San J aojoin Local Health District. <br /> APPLICANT'S SIGNATURE X 2 <br /> FOR DEPARTMENT USE ONiI. <br /> Fee Is Due: Q ANNUALLY ,❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1�&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> f PRORATION y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r �aa's s - <br /> Received by Date.`: Receipt No. Permit No. ': EHAZELTON <br /> lssuance Da Mailed DeliveredAPPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 A .O.Bo:2009 STOCKTON,CA 95201 <br /> i <br />