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Applications Will Be Processed When Submitted Properly Completed. Be SureTosign >ineAppliCi8►uon. <br /> APPLICATION <br /> T b 2 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icationn iss phereby�adde-tto carry on busin s in the jurisdictional area of tASJoa�qui ocal Health District <br /> y Busine a (DBA) /►�- Addre saOwnerAddre <br /> e. <br /> Firm Partners, Addresses and Telephone Numbers _t_C _ �— <br /> aBusiness Telephone No. .. 3`3 Emergency Telephone No. <br /> Contractor Licence No. <br /> Title OU) L),f 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) <br /> Serial No. 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 <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 /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addres ocation .2Ll N <br /> Owner Address C <br /> SEPTIC TANK El LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT (/, <br /> t' <br /> Its PERMANENT ❑ TEMPORARY 'NEW ❑ REPAIR ❑ OTHER J <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 .4 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) qN <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 WN <br /> Operator Name Where Certified S <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 10 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Fl. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 have red this ap ion and that the work will be done in accordan�WithSan Joaquin County <br /> ordinances, state laws, a r and regula f e San Joaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE X <br /> J <br /> 1 <br /> FOR DEPARTMENT USE O <br /> Fee IS Due. © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J ary & eceived By January 31 ❑ July 1 &Received By Jury 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE A E $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date rM6ai3ed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 160]-E_HAZELTOK AVE.,P.O ox 2009 STOCKTON,CA 95201 <br />