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oy. <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION ' <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> LIQUID WASTE <br /> Applicatio is hereby m to rry on in the jurisdictional area of the S qui ocai He t stri <br /> Business Name A) Address <br /> f <br /> zz Owner <br /> Address ° <br /> J Firm Partners, Addresses and Telephone umbers <br /> III Business Telephone No. �� _ Emergency Teiephone No. <br /> j Contractor Licence No. Z D <br /> Date <br /> Applicants Name (Print) <br /> -Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 <br /> Serial No. I 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 i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> M 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> i Test Date/Time <br /> Test Location <br /> 4. .99-SANITATION PER71 - mC <br /> Job Addre cation p <br /> Owner� -- Address <br /> SEPTIC TANK ❑ CESSPOOL I"-LEACHING FIELD SEEPAGE PIT ❑ PACKAG PLANT <br /> ❑ © OTHER <br /> ❑ PERMANENT ❑ ® <br /> TEMPORARY 'lIEW REPAIR • <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 /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 3 Where Certified <br /> Plant Location <br /> No, Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 -SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> R <br /> ( <br /> I hereby certify that I have a d this appli io and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rlll and regulatio e n Joaquin Local Health District. <br /> Yoe-, <br /> APPLICANT'S SIGNATURE <br /> A <br /> r FOR DEPARTMENT USE ONLY <br /> M <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT OPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r REMIT <br /> i BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> } PRORATION <br /> PLUS 1 O <br /> PENALTY <br /> 4 OTHER r <br /> I OTHER <br /> a � I <br /> _ 7 <br /> R <br /> Date Receipt N. - Permit No Issuance ate - Mailed elive ed <br /> eceived by <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON;C 5201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />