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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. � <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ct <br /> AppI icat ion is h reby made to arty on bu mess in thy' risdi nal area of the San oaq �l Health D i <br /> wBusiness Name (D ) Address <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. — Emergency Telephone No. ; <br /> Contractor Licence No. <br /> Title <br /> 4 oat Date <br /> 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) -J <br /> For July 1, June 30, 19 Disposal Sites <br /> 1 <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. Liccnse Renewal No. <br /> Serial 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 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or <br /> R.C.E. Name R.S. or R.C.E. No. <br /> Test _ Test Date/Time , <br /> 4. PERMIT <br /> Job Address/ ation <br /> Owner Address W <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD I� S EPAGE PIT ❑ PACKAG�PLANT <br /> ❑ OTHER ' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR �Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -3une 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> 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 /> i� SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> k ❑ 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 I <br /> ordinances, state laws, and ru and regulations of he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> A <br /> I <br /> i FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due: ❑ ANNUALLY PER UNIT El SITE Cl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 REMIT ' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUN <br /> FEE <br /> l <br /> LESS <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> L <br /> 3 V <br /> Received by - Date Receipt No. Permit No. Issu nce Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 a STOCKTON.CA 95;011 „ <br />