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I' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION a <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' he by ade to car on�ssiinGess in the jurisdictional area of the n J aquin Local Health District / <br /> HBusiness Name (DBA) LJ. + ��t. '�+'+���- L'' Address. /, <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. rt <br /> Applicants Name (Print) Date T l <br /> Please check Applicable Category (1-7) and Fill in the Required Information r ,` <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. i <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 /> Testi ocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Add s/L�oi�ation n' d� <br /> Owner �LT��O �� Address p 'r/0 r� <br /> 11 SEPTIC TANK ❑ CESSPOOL IZL LEACHING FIELD gSECPAGEPIT ❑ PACKAGE PLANT <br /> .PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER i <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. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> , <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 Y <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, a rules and re ulations a San Joaquin Local Health District: <br /> i <br /> APPLICANT'S SIGNATURE X <br /> ed <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> Fee 15 Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE 11 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 C AMOUNT <br /> FEE S [ T V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY (J <br /> OTHER <br /> OTHER <br /> � g1�t� <br /> Received by Date Receipt No. Permit No lissuahce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />