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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby mad to car on usiness in tjie juridictional area of the San Joaquin Local Health District <br /> OF Business Name (D ) ( Address <br /> z Owner Address <br /> a <br /> j Firm Partners, Addresses and Telephone Numbers I <br /> a. Business Telephone No. $/0.6 Emergency Telephone No. <br /> Contractor Licence No. Z <br /> Applicants Name (Print) Title Date Z a '�d <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 14" Disposal Sites <br /> Description(Make/Yr., Color) _ <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity— _ Gal., Weights &Measures No. <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. Name R.S. or R.C.E. No. <br /> Test Dation Test Date/Time - <br /> 4. SANITATION PERMIT ,- <br /> Job Address/Location <br /> Owner Address <br /> 11SEPTIC TA ❑ CESSPOOL LEACHING FIELD--- <br /> ❑ PACKAGE PLANT <br /> ❑ PERMAIVENT ❑ TEMPORARY ❑ NEW ❑ REPAIR —❑ OTHER W <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> Y <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - <br /> Operator Name Where Certified <br /> Plant Location 3 <br /> Plant Capacity <br /> # 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 /> 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 d regulations of th Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> III;iuii Cj 5(SS"& � <br /> ..3jav <br /> 8b <br /> Received byDate Receipt No. Permit No. Issuance Date ai d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />