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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 he by made to carry on business in the jurisdictional area of the San.Joaquin Local Health District <br /> Business Name (DBA) �� s - Address' <br /> i Owner . Address <br /> J,Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. a Emergency Telephone No. <br /> Contractor Licence No. : . <br /> Applicants Name (Print) z Title-, Date r <br /> Please check Applicable Category(1-7)and Fill in the Required Information . <br /> i <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <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 t <br /> No. of Chemical Toilets Stored <br /> s - <br /> 3. ❑ PERCOLATION TEST g <br /> R.S.or R.C.E.IName R.S.or R.C.E. No. -- { <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ I <br /> Job Address/Location 41,4Z' t <br /> Ow96r Addresses <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT } <br /> 1 <br /> Di <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW D REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 l ( t DQ <br /> e Type Construction Disposal Site ` <br /> - .. ,_ , r I --C <br /> t No. of Units Equipment'Storage/Clea"ning-L-ocation(5} <br /> f 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 {k <br /> l - <br /> Operator Name Where Certified <br /> Plant Location - <br /> Plant Capacity Fes`No."Units Served = ^ <br /> i 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. 1 <br /> . ^- � ,,,..._fir•. ,. <br /> I hereby certify that I have prepared'.1 is`application and,that the work•willbe done in accordance with San Joaquin County <br /> ordinances, state laws,'and rulesS-and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE•X <br /> FOR DEPARTMENT USE ONLY <br /> ) <br /> _ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE » ❑.EACH- ❑ January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> REMIT <br /> I BILI INGT REMITTANCE AMOUNT DUE CHEC ED <br /> BASE EXPLANATION $ �. <br /> BATE DATE _ REMITTED t AMOUNT <br /> FEE f <br /> a <br /> LESS45 <br /> I t <br /> PRDRATION <br /> PLUS a t R <br /> PENALTY <br /> OTHER f x ,. <br /> _- <br /> OTHER .. �' "�.'^.^'^"^-- -_ .�.T,_,,....., . r-,-..--' ._*—p,�.�..�-.-...--- •r-,....�.... . <br /> t Received by Date Receipt No. Permit No. I uance Date Mailed, Delivered <br /> APPLICANT-,-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 21309 STOCKTON,CA95201 <br />