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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> . `� ENVIRONMENTAL HEALTH PERMIT <br /> i LIQUID WASTE , <br /> i° <br /> Appllcation is her by made to carry on business int a jurisdictional area of the San Joaquin Local Health D'strict <br /> y Business Name (DB <br /> c Address <br /> z Owner m 'i Address - <br /> a <br /> Ll Firm Partners, Addresses and Telephone Numbers <br /> aIM. Emergency Telephone No. <br /> M <br /> Business Telephone No. 1 <br /> Contractor Licence No. 3 <br /> L Applicants Name (Print) iM. Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> I, 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. IM, CAL. License No. CAL. License Renewal No. <br /> Capacity iM Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored iM <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E.No. <br /> Test Location I Test Date/Time <br /> F 4. ❑ SANITATION PERMIT / <br /> I Job Address/Location <br /> Owner Address <br /> SEPTIC TANK ❑ CESSP4 <br /> OOL LEAC NG FIELD SEEPAGE PIT PACKA E PLANT <br /> PERMANENT ❑ TEMPORARY ";k NEW ❑ REPAIR ❑ OTHER Y 06 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> F <br /> Type Construction 1. Disposal Site <br /> No. of Units 1�, Equipment Storage/Cleaning Location(s) <br /> ( 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Ii <br /> Operator Name Where Certified <br /> ;A <br /> Plant Location I� <br /> f Plant Capacity �M No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Ih une 30, 19 <br /> SIZE: ❑ Less Than 1,000 S0,0 ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r _ <br /> I hereby certify that.l have prepared this application and that,the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and r Ie nd gulatio If the San Joaquin ocal Health District. <br /> f - <br /> APPLICANT'S SIGNATURE X 'I <br /> 'I <br /> _ FOR DEPARTMENT USE ONLY <br /> PER ❑ PER SITE ❑ EACH ❑ January 1 Received By January 31 El July 1 &Received By July 31 <br /> Fee IS Due: El ANNUALLY <br /> REMIT <br /> .F.I. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FI o <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> r I�G OTHER � <br /> OTHER d <br /> p <br /> Received by Date Receipt No. Permit NO 1ss ce Da Mailed elivered <br /> APPLICANT—RETURN ALL 6OPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON-AVE.,P.O.BoK 2009 STOCKTON,CA 95201 <br />