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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicatson. t <br /> 11 APPLICATION <br /> II (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i 7e;,eby rpade o,carry n busines .'n the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) f� ate > Address <br /> aDwner Address <br /> 1 Firm Partners, Addresses and Tel hone Numbers <br /> a. Business Telephone -"No. YOI r &I/ Emergency Telephone No. <br /> Contractor Licence No. � e _ } <br /> a Applicants Name {Printf ! f 1�E€ [1 TitleJ/ Date �=- ,f 1 `%f i <br /> Please check Applicable Category (14) and Fill in the Required Information r <br /> 1. ❑_PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 7 Disposal Sites <br /> Descriptigrr(Make/Yr., Color) Ij <br /> Serial No. '" CAL. License No. CAL. License Renewal No.• <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address II rAI <br /> 2. ❑ PUMPER YARD �i r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored �� I <br /> No. of Chemical Toilets Stored �I <br /> 3. ❑ PERCOLATION TEST IM I <br /> R.S. or R.C.E. Name I). R.S. or-R.C.E.No. <br /> Test Location Test Date/Time a <br /> 4. p.SANITATION PERMIT <br /> Job Address/L <br /> Owner cation " -`��'^'✓� <br /> 116, y `Address 1 <br /> �.�'•- �1�:;,:--^� s..��� � u ��•f:, <br /> ❑ SEP_,TIC TANK ❑ ESSPOOL -"` A LEACHING FIELD ❑ SEEPAGE PIT ❑PACKAGE PLANT <br /> _ PERMANENT ❑ TEMPORARY;, NEW REPAIR OTHERC <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 r <br /> Type Construction it Disposal Site Z{Altid. i <br /> No. of Unita IM Equipment.Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -"JLne 30, 19 � <br /> Operator Name �! Where Certified <br /> Plant Location <br /> Plant Capacity" 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. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. l <br /> I hereby certify that I have prepared this al5pli"cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and rf�gulationsXf the San Joagvin Local"Health District. <br /> APPLICANT'S SIGNATUREX '� <br /> FOR,DEPARTMENT USE ON <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE ,❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS - - <br /> PENALTY <br /> OTHER <br /> OTHER i! _ <br /> Ali <br /> Received Received by <br /> Dale ij- Receipt No. Permit No.s Issuance Da > Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVEE'P.O,Sox 20[19 STOCKTON,CA 95201 <br /> i' <br />