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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 /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r nosiness Name(DBA) Address` <br /> z Owner Address <br /> 4 <br /> J Firm Partners,Addresses and Telephone Numbers <br /> i Business Telephone No. -�p7� Emergency Telephone No. <br /> Contractor Licence No. 3 / .y3 <br /> L Applicants Name(Print) ✓7 - C -� Title Date n <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) <br /> Serial No. CAL.License No. GAL.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 /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Tes Location Test Date/Time <br /> 4. , SANITATION PERMIT,/ <br /> Job Address/Location <br /> Owner AG 5e2 r'Q Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 3D,19 ` <br /> v Construction Disposal Site <br /> ..o.of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1t_.June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No.Units Served <br /> 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 Use&Amount/Mo. <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 rul and re ulati s oft San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 19 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received sy January 31 ❑ July 1 8 ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Gy 4 0 <br /> LESS (/ <br /> PRDRATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 fl�L b Ali—~st <br /> Received by Date Receipt No. Permit No. Issuance Date Malied Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 7801 E.HAZELTON AVE.,P.O.Box 2= sTOCKTON,CA 95201 <br />