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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> y (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 Sa Paquin Local Health District <br /> Address r •°! <br /> yBusiness Name (DBA) <br /> r Address <br /> z Owner <br /> — <br /> < <br /> ° <br /> Firm FiPartners, Addresses and Telephone Numbers <br /> Z. Emergency Telephone No. <br /> CL Business Telephone No. �} <br /> Contractor Licence No. . ,,�� Date <br /> Title [� <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 /> 0 <br /> Description(Make/Yr., Color) CAL, License Renewal No. 4- <br /> SerialNo. CAL. License 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 i f <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.orY-R.C.E. No. <br /> R.S. or R.C.E': Name <br /> Test Date/Time a , <br /> Test Locatioi q4. <br /> a r t ,�; ? <br /> 4. 11 SANITATION PERMIT <br /> Job Address/Location <br /> Owner ' Address � =f` <br /> '" ❑ PAC+�AGE PLANT''- <br /> ❑ SEPTIC TANK ❑ CESSPOOL EACHIfVG FIE I] SEEAAR E PIT OTHER 1 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW � a <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal'Site C7 <br /> No. of Units: Equipment Storage/Claeaning Loc IONS) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> 6. PAC Where Certified <br /> Operator Name <br /> t L <br /> Plant Location <br /> flits SeTved'"� <br /> Plant Capacity N =` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: =Less Than 1,000 Sq. Ft., ❑ More Th1an 1,000 Sq. Ft. <br /> 13 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. All <br /> e <br /> % F. <br /> 13hereby certify that I have p pared this application and,that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the.g an Joaquin Local Health District. <br /> APPLICANT'S-S'GNATURE X ) <br /> 1I� FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 E,.ReceiveREM4Td By uly 31 <br /> 'c, BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> da <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ) <br /> PENALTY <br /> OTHER ? <br /> QQ <br /> - _^ �p. - <br /> Date Receipt No. Pesmit No: ssuanc Date Mailed Delivered <br /> Received by - - 1801 E HAZEL <br /> AVE.,F.O.Bow 2009 STOCKTON,CA 95201 <br /> ` .APPLICANT—RETURN ALL-COPIES-TO:w. ENVIRONMENTAL HEALTH PERMITS€RVICES. <br />