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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Q� APPLICATION �f <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> LIQUID WASTE 4 <br /> Application is he by made to caM on siness in the Iur' dictional area of the San Joaquin Local Health District r <br /> yBusiness Name BA) Address <br /> aOwner - Address - <br /> 1.Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. T6 z J-1 0 Emergency Telephone No. € <br /> 9 <br /> Contractor Licence No. 32-Z <br /> L Applicants Name (Print) Title ���� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 3 <br /> 1. ❑ PUMPER VEHICLE PERMIT 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. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. i _ <br /> Equipment Parking Address r , <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored 4 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST k <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Nest Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/LD tion /I � <br /> Owner <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 1EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER -O <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -►-r-.rf O ' <br /> Type Construction Disposal Site 0, <br />..r No. of Units Equipment Storage/Cleaning Location(s) <br />} 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> i Plant Location —` - �73 <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. _ <br /> -w li <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an gulations of the San Joaquin Local Health District. 11 <br /> APPLICANT'S SIGNATURE X . <br /> I V <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &F1e -ived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMIT ANCE $ AMOUNT DUE CHECKED <br /> DATE D REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> 3 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cl1 -7� <br /> l Received by Date Receipt No. P rmit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br /> �� 6f7f^ <br />