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`1 plicationsWill Be Processed When Submitted Properly Completed. tie Sure 1osign Inerppig—ti il. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ,. ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE \ <br /> Applica 'o Is hereb made to carry on business in the jurisdictional area of tYie n Joi!�in I ocal Hl�t[ (strict <br /> ,,Business Name BA). e r Address C). t 'T <br /> z Owner 4 A -L Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 52" S-1 — - Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name {Print) Title — e'1^ Date <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, 19 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 Location ' Test Date/Time T <br /> 4. 11 SANITATION PERMIT73 41 5 /,67 <br /> /,67/,67Job Address/Location Ce- <br /> Ow r Address <br /> SEPTIC TANK ❑ CESSPOOL E HIN" P5;CG FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT - <br /> ❑ PERMANENT 11 TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> _ ._ - .... <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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 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. <br /> . r <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 and 71ation54f the San Joaquin Local Health District. ! <br /> APPLICANT'S SIGNATURE Xril <br /> _- <br /> '' <br /> FOR DEPARTMENT USE ONLY <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �FEES �1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is ante D e Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. AZELTON AVE.,P.O.Box 209 STOCKTON,CA 95201 <br />