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Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign 1nAppucauon. <br /> APPLICATION <br /> { Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h. by made to carry a.business in the jurisdictional area of tjSan oaquin Loll Health Districts,. <br /> 3usine65 Name (DBA) Address <br /> 1 <br /> 7wner Address <br /> =irm Partners, Addresses and TelepWne Num e <br /> 3usiness Telephone No. -r b. d Emergency Telephone No. <br /> ;,ontractor Licence No. <br /> Dae <br /> 4pplicants Name(Print) <br /> Title t <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ' <br /> ) <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 /> 4 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMIT � LV._,� <br /> Job Addre Location � �-/t/ <br /> Owner EW ,�,/ Address <br /> SEPTIC TANK 11 CESSPOOL Ja LEACHING FIELD $SEEPAGE PIT ❑ PACKAGE PL NT <br /> PERMANENT ❑ TEMPORARY g NEW ❑ REPAIR ❑ OTHER <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 <br /> Where Certified <br /> - <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity I <br /> 1 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. c� <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 and regul tions of a an 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 1 &ReceiveRdEByl July 31 <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 I <br /> 4 <br /> OTHER <br /> r Received by Date Receipt No. Permit No. Issue a at Mailed Delivered <br />�_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE5 1601 E,HAZELTOIN A .Box 2009 STOCKTON,C0.95201 <br />