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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Ign e p <br /> APPLICATION <br /> I (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ly}ade to carry <br /> us l i the dictio I area of the San Joaquin Local Health DistriFt <br /> Application is Y O � Address�7 t St3 �� C4 <br /> Business Nam <br /> aOwners Address <br /> a Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> f a Business Telephone No. / <br /> Contractor Licence No. 9�r��' u <br /> Title Date <br /> LApplicants Name (Print) S <br /> Please check Applicable Category (1-7)and Fill in the Required Information ! <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) U <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL, License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> ` For July 1, June 30, i9 ; <br /> No. of Vehicles Stored <br /> i No. of Chemical Toilets Stored <br /> 3. 0-:PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> C Test Date/Time <br /> Test Location <br /> f 4. SANITATION PERMIT / l`' <br /> Job Address/Location Co f - <br /> Owner Address <br /> ❑ SEPTIC TANK © CESSPOOLLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> pl PERMANENT 13 TEMPORARY ❑ NEW >.REPAIR ;ROTHER SIX/iq jC 1,2_ <br /> G 7 <br /> 5. IJ 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 Where Certified <br /> Operator Name <br /> Plant Location <br /> :No. Units Served <br /> E Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> k SIZE: - ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> f ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <br /> [ t <br /> E <br /> p 1ic and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that l have prepared this a <br /> ordinances, state laws, and rules r i soft a San aquin cal Health Qistrict, <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 &Received By July 31 <br /> REMIT <br /> k BILLING REMITTANCE AMOUNT DUE CHECKED <br /> P BASE EXPLANATION PATE DATE REMITTED AMOUNT <br /> � FEE <br /> � s D� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER k. <br /> (G <br /> I Receipt No. Permit No- Issuanc ate Mailed Delivered <br /> Received by Dafe <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009� STOCKTON,CA 45201 <br /> t <br />