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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 /> I Application is he by made to carry on bl l ss in the jurisdictional area of the Sa oaquin Lo I Health District <br /> yBusiness Name (DBA)77 Address <br /> aOwner_.. �. y%�r � L ��� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> y a Business Telephone No. �_ Emergency Telephone No. <br /> _J Contractor Licence No. $ j <br /> L Applicants Name (Print) Title f4' N � Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information Q <br /> ;'- 1. ❑ 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 /> i 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 /> No <br /> R.C.E.R.S.or . <br /> R.S. or R.C.E. Name - <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT .t <br /> Job Address/Lo ation _ <br /> Owner = 1 7 —1V Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL EILEACHING FIELD ❑ SE PAGE PIT ❑ PACKAGE PLANT <br /> ❑ <br /> I <br /> 1:1 PERMANENT 11 TEMPORARY ❑ NEW _ REPAIR OTHER A <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 e <br /> t Type Construction Disposal Site <br /> ' No. of Units Equipment Storage/Cleaning Locations) <br /> - 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> a Plant Location <br /> I Plant Capacity No. Units Served <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/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 /> ordinances, state laws, and rules d regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> i 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 /> t DATE '" DATE REMITTED AMOUNT <br /> �5 Y FEE .� <br /> LESS <br /> PRORATION <br /> J ' <br /> PLUS d <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER ' <br /> r <br /> I, Received by Date Receipt No. Permit No, Issuance Date Mailed De ivered <br /> APPLICANT7-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITYSERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009' STOCKTON,CA 95201- _ <br />