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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 /> Appl ication ' hereby m de to car on b siness in tN jurisdictional area of the San Joaquin Local Health Pistrict <br /> y Business Name (D A) Address <br /> z Owner. Address �- -� <br /> d <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Z <br /> L Applicants Name (Print) _-_ Title Date <br /> Please check�Applicable Category (1-7)and Fi�inthe�Requlrd Information <br /> 1. ❑ PUMPER,VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) D <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 <br /> No. of Chem lcal,Toilets Stored- _ # <br /> 3. © PERCOLATION TEST «T r <br /> R.S. or R.C.E. Name_- R.S. or R.C.E. No. <br /> Test LL tion Test Date/Time <br /> 4. LU SANITATION PERMIT <br /> Job Address/Location 5 D� <br /> Owner C Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL © LE HING FIELD SEEPAGE PIT 0 PACKAGE PLANT,�3 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity - No FUnits Served f l <br /> 7. 0 LAUNDRY For July 1, -June 30, 19 ""'�""` .�1- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I] DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <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 AI <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due'. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By JanuaZo <br /> ❑ Jul 1 &Received By July 31 <br /> R IT <br /> BASE EXPLANATION BILLING REMITTANCE $ E CH KED <br /> DATE DATE REMITTED A LINT <br /> FEE 4 L- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Q <br /> r fJ <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered I I I ! <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> - <br />