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Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION <br /> y (For Non-Transterable,Revocable, and Suspendable) SEPTAGE s <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Appl icatio is h y made o ry on business in the jurisdictional area of the San Joa uin LocaLHe D�ri <br /> Address <br /> y Business Name {DBA) <br /> Address. <br /> 4 Owner <br /> Firm Partners, Ad resses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No: <br /> Contractor Licence No. Title Date <br /> Applicants Name (Print) _. ... v I <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) CAL. License Reriewal No. <br /> Serial <br /> Description <br /> CAL. License No. <br /> eights &Measures No. <br /> Capacity Gal.,W ' <br /> i <br /> Equipment Parking Address Ir <br /> 2. ❑ PUMPER YARD , <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored } y <br /> 3. ❑ PERCOLATION TEST <br /> . t R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name i Test Date/Time <br /> Ik # <br /> Test Location <br /> 4. ❑ SANITATION PERMIT �— s <br /> Job Addres o tion Address S <br /> Owner ' ❑ PACKAGE PLANT <br /> 1SEPTIC TANK ❑ CESSPOOL- ❑ LEACHING FIELD SEEPAGE PIT <br /> REPAIR ❑ OTHER <br /> ❑ PERMANENT 13 TEMPORARY ❑ NEW I <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) v <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> k � No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July1,-rune 30, 19— <br /> SIZE: <br /> 9SIZE: ❑ Less ThanOi 00 So. Ff, E1¢tkore.Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 3 > <br /> I hereby certify that I h'dve�Prepared this application and that the work will be done in accordance with San Joaquin County <br /> San Joaquin Local alth District. <br /> ordinances, state laws,'and rules and�'reegulations e <br /> APPLICANT'S SIGNATURE X 4 <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT.. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t 8 Receiv REMIT <br /> d By UIy 31 <br /> i� r-L- BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPCANATION DATE DATE -REMITTED AMOUNT <br /> FEE <br /> F LESS <br /> PRORATION <br /> PLUS i s <br /> ' PENALTY <br /> OTHER " �! <br /> OTHER <br /> s I1Q ` <br /> Receipt No Permit No. 4ssuance Dale Mailed Delivered <br /> Received`by r Date - <br /> �1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br /> APPLICANT— <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> I <br />