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=fT <br /> Applications Will Be Ill sed When SubAPPL'CATIONCompleted. Be Si,-n To Sign The Application. <br /> `,.1 <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in t e jurisdictional area of the�n Jo ui i gcal Health District <br /> Address <br /> wBusiness Name (DB m <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> sBusiness Telephone No. I ) <br /> Contractor Licence No. Title Date <br /> L 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 /> Description(Make/Yr.,Color) CAL.License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> -TFor 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 Test Date/Time <br /> Test Location p <br /> 4. ❑ SANITATION PERMIT � f � ! �^ � 111111i 01 <br /> Job Address/Location �511 F ill <br /> Owner Address <br /> SEPTIC TANK 13 CESSPOOL XLEAC NG FIELD SEEPAGE PIT ❑ PACKA E PLANT <br /> PERMANENT ❑ TEMPORARY NEW <br /> ❑ REPAIR ❑ OTHER C <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site . <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> t <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified _ <br /> Operator Name <br /> Plant Location <br /> 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/Amourl <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r le nd gulatio f the San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> PER UNIT ❑ July 1 8 Received 8y July 31 <br /> Fee IS Due: 13 ANNUALLY ❑ ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> *445 <br /> FEE <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> c <br /> OTHER <br /> OTHER q <br /> I. issLwce Oa Mailed livered O <br /> Receipt No Permit No. <br /> Date Reteired by u,Y/CFGVICFS 1601 E.kAIELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />