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feted. Besure ioa�y�� 1 ^,.r.. <br /> Applications Will Be Processed When SubAPPLiCATiONProperly p <br /> =J SEPTAGE <br /> (Far Non-Transferable,Revocable, and Suspendab e } <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 /> Address <br /> Cb Business Name (DBA) Address t" <br /> a Owner <br /> j Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. I <br /> aBusiness Telephone No. 747 <br /> Contractor Licence No. Title Date <br /> Applicants Name (Print) 4Please check Applicable Category (1-7)and Fill in the Required Information 4 <br /> RATION (FOR EACH VEHICLE) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTr <br /> June 30, 19 Disposal Sites I <br /> For July 1, I <br /> Description(Make/Yr., Color) CAL. License Renewal No. , <br /> CAL. License No. r <br /> Serial 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 R.S. or R.C.E.No. <br /> R.S. or R.C.E, Name <br /> t, Test Date/Timet <br /> Test Location <br /> j 4. ® SANITATION PERMIT C C <br /> i � <br /> Job Address/Location Address 8 2, 0 v <br /> Owner ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGEPLANT <br /> SEPTIC TANK ❑ CESSPOOL 13 REPAIR OTHER <br /> ❑ PERMANENT 11 TEMPORARY <br /> 11 NEW <br /> g. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -5 <br /> Disposal Site <� <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name , <br /> Plant Location 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 /> t the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and th <br /> a <br /> ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. <br /> G <br /> APPLICANT'S SIGNATURE X <br /> i FOR DEPARTMENT USE ONLY <br /> {�. El January 1 &Received By January 31 ❑ July 1 &Received By Juky 31 <br /> REMIT <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNIT ❑ PER SITE EACH BILLING EMITTANCE $ AMOUNT DUE . CHECKED <br /> BASE EXPLANATION <br /> PATE DATE REMITTED AMOUNT <br /> , <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY' 1® <br /> i OTHER ` <br /> OTHER \ �[� <br /> Receipt No. Permit.NO. <br /> I uance Date Mailed Delivered . <br /> Received by - Date - 1 1 E- AZELTON'�jYE:,P.O,13 2009 STOCKTON,-CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICE5 t,(} ��� <br />