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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign IneApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application isAhereby made o carry on busine sin the j isdictional area of the San Joaquin Local Health District <br /> Business Name BA) .e Addres <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. ' � � Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date � !7{ <br /> Please check Applicable Category (1-7)and Fill�th. eq fired�IntormaItion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (1} <br /> For July 1, June 30, 19 Disposal Sites 1 <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 ovation } Test Date/Time <br /> 4. � SANITATION PERMIT 2 ti <br /> Job Address/Loc tic <br /> O er Address <br /> L,GprSEPTiC TANK ❑ CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> L�1 PERMANENT ❑ TEMPORARY l� NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> JC <br /> Plant Location <br /> Plant Capacity No.-,Units Served /�`� �• <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 vj�� f [ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 'Cl DRY CLEANING, Chemicals Used/Amount/Mo. � ' Ilk <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 rules d regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED Jfp AMOUNT <br /> z� <br /> FEE �J a- T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON E.,P.O.Box 2009 STOCKTON,CA 95201 <br />