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6r, <br /> Applications Will Be Pror��sed When Submitted P ATIONpleied.Be Sure To Sign The Application. <br /> r or Non-Transferable,Revocable, and Suspendabta SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ~ <br /> Applicatio is ere made to car on business in the'uri} sdictionalAa�tl $5th San Joa uin Local Health District <br /> `Business Name (DBA) Address <br /> z Owner <br /> 4 <br /> 2 Firm Partners, Addresses and T lho <br /> e ne Numbers Emergency Telephone No. <br /> OR <br /> Business Telephone No. <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 <br /> A H VEHICLE) <br /> Disposaes <br /> For July 1, June 30, 19 <br /> Description(Make/Yr.,Color) CAL. License No. CAL. License Renewal NO. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <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 Test Date/Time <br /> Test Location Jill <br /> 4. Pt SANITATION PER IT ;JI- /" .0 <br /> Job Ad dr s! ocation r r Address <br /> OwnerG FIELD 10 SEEPAGE PIT El PACKAGE PLANT <br /> J9 SEPTIC TANK 11 CESSPOOL LEAC <br /> CESSPOOL HIN ❑ REPAIR ❑ OTHER <br /> PERMANENT ❑ TEMPORARY ® NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <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�gMore Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> state laws, and rules and regulatio s of the San Joaquin Local Health District. <br /> ordinances, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 1 &Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH January S AMOUNT DUE CHECKED <br /> BILLING REMITTANCE pEµITT AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION \ <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> OTHER �-7 J <br /> I—x�p ailed livered <br /> Receipt No. Permit No. <br /> Received Gy Dale 7601 E.HAZELTON AVE.,P.O.Box 2909 5TOCKTON,CA 9 <br /> ENVIRONMENTAL HEALTH PERM ITISERVICES <br />