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.__�. . � ­_ -_. . ... <br /> erly Completed. Be Sure To SignTheAppucauon.. <br /> Applications Will Er Processed Wten Submitted Pro <br /> APPLICATION ` <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT k <br /> LIQUID WASTE <br /> Applicati is hereby m e t �rryo usin ss the jurisdictional area oft he S n Joa Local:Fjealth strict <br /> D <br /> e BA Address f� ` <br /> Busines (F Address <br /> aOwner <br /> Firm Partners, Addresses and Telephone Numbers3 Emergency Telephone No. <br /> a Business Telephone No. <br /> t <br /> Contractor Licence No. IRJ K Title- Date <br /> L Applicants Name (Print) J 1 <br /> Please check Applicable Caiegory(7-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -1 <br /> For July 1, June 30, 19 Disposal Sites <br /> + <br /> Description(Make/Yr., Color) CAL. License No. CAL, License Renewal No. <br /> Serial No. <br /> I <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD F <br /> For July 1, June 30, 19 <br /> } No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. © PERCOLATION TEST. R.S. or R.C.E.No. <br /> I R.S. or R.C.E. Name <br /> TTest_Date/Time <br /> Test Location <br /> 4. SANITATION PERMi , <br /> Job Addres ocation <br /> Owner Address <br /> CYSEPTIC TANK [3 CESSPOOL EL-LEACHING FIELD G-5EPIT 0 PACKAGE PLANT <br /> &r15RMANENT ❑ TEMPORARY W ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> �. Type Construction , <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i 6. © PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> i Where Certified <br /> Operator Name <br /> ' Plant Location <br /> k E No. Units Served <br /> Plant Capacity <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 Used/Amount/Mo: <br /> repared this app ication and <br /> 1 _ - <br /> I hereby certify that I have pthat the work will be done in accordance with San Joaquin County <br /> ordinances, state lawsa, an rules d regula of a San Joaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Sanuary 31 ❑ July 1 &ReceivedREMIT <br /> uiy 31 <br /> BILLINGREMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED - AMOUNT <br /> FEE 4 �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No: I uan Date Mailed Delivered <br /> Received by Date - <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO[ ENVIRONMENTAL HEALTH PERMITlSERYICES rp� <br />