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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Y <br /> APPLICATION _ <br /> y (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE I <br /> Application' ereby e o rry on business in the jurisdictional area of th an J aquin Local Healt ri <br /> F Business Name (DBA) os Address < t <br /> aOwner Address <br /> Firm Partners, Addresses and/T� ne Nun1bers. <br /> aBusiness Telephone No. _ S Emergency Telephone No. -A <br /> _J Contractor Licence No. � <br /> Applicants Name (Print) i- - - _E Title �� Date Y-48-Z-1 I <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yv. Color) '— <br /> Serial No. CAL. License No.---�} CAL.License Renewal No. <br /> Capacity ' -Gal Weights &Measures No. . <br /> Equipment Parking Address 4 <br /> 2. [3 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 9 <br /> R.S. or R.C.E. Name ____ R.S. or R.C.E. No: - ?R .. 4 5 <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMITr <br /> Job Address/Location ' _ �� L D <br /> Owner 2�; z )1z1V Address <br /> SEPTIC TANK ❑ CESSPOOL '' f EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT © TEMPORARY NEW 11 REPAIR ❑ OTHER p� <br /> 5. 1:1 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction- ` �s = Disposal Site <br /> No. of Units Equipment Storage/Cleaning�Location(s) ' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ry Operator Name i _ -- _ Where Certified <br /> Plant Location + <br /> Plant Capacity No hinits Served *' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 9 Jt� <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, an r es and r u tions t San uin Local Health District. ! <br /> APPLICANT'S SIGNATURE X <br /> F FOR DEPARTMENT USE ONLY ¢ - <br /> s <br /> R Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By J nuar 1 [] July 1 &Received By July 31 <br /> 7 BILLING REMITTANCE $ el <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ,,,,..DATE,,,.-. � DATE. �REM I E AMOUNT <br /> -FEE <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER v _ <br /> OTHER a .. <br /> a - ' <br /> Received by Date Receipt No I IssulanIvni Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL .;P.O.Box 2009 STOCKTON,CA 95201 <br />