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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable;'�ReVoc8ble;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIb WASTE <br /> Application i reby madetc ar busi s in the'uri tional area of the Sa oaquin ocal Health District <br /> Business Nam 13 Address -- <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> a Business Telephone No._ c,r .. - <br /> Contractor LicenceNo. <br /> Applicants Name(Print) Title Date <br /> Please check Applicable Category(1-7)-and Fill In the�Reqquke�djomn�afin <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr„Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> r) 2. ❑ PUMPER YARD 1 <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 LLttion Test Date/Time <br /> 4. SANETATION PERMIT %11 <br /> Job Address/ ocation <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEA HING FIELD �� E PIT 13 PACKAGE PLANT <br /> ❑ PERMANENT © TEMPORARY ❑ NEW M-<PAIR © OTHER <br /> S. ❑ 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 /> i <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. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i&Received By January 31 ❑July 1&Received Fly 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 /> PLNALTY ' J <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lee ance Date Mailed eli erad <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICCES 1861 E.'HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> f"� <br />