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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> .. (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is.liereby made t9 cury on business in th juri ctional area of the Sa oaquin Local Health Distn <br /> Business Name (DB ) � Addresses ' a� ' <br /> i Owner-- Address <br /> a <br /> 01 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. —� 6 � 0_i Emergency Telephone No. <br /> Contractor Licence No. �- <br /> Applicants Name (Print) Title Date C=2 <br /> Please check Applicable Category (1-7) and Fill in�theReq�ulredfo ation I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) –� <br /> For July 1, June 30, 19 4 Disposal Sites _j <br /> Description(Make/Yr., Color) . <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> r <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 L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 2– > <br /> Owner 0_" Address <br /> �EPTIC TANK C3CESSPOO-T LEACHING FIELD T ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, lune 30, 19 <br /> Operator Name _ a ' Where Certified <br /> Plant Location I <br /> Plant Capacity No..Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— AllF <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than-1,000 Sq'Ft— ` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joe i ty <br /> ordinances, state laws, and rut nd Ilations of t an aquin Local Health District. Y <br /> APPLICANT'S SIGNATURE X <br /> r <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 /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> N <br /> OTHER ( *� <br /> Received by Da%e Receipt No. Permit No. pssuancO Date - Mailed /Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />