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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> y (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i LIQUID WASTE <br /> Applicationi reby made to parN on busirius in the'url die 'onal area of the S Joaquin Local Health District <br /> yBusiness Name `A) "- Address �0 '�� 26 <br /> aOwner . Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> M <br /> Business Telephone No. S/D ----- Emergency Telephone No. �) <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date ����'��� <br /> Please check Applicable Category(1-7) and Fill in the Required nformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �O <br /> For July 1> June 30, 19 Disposal Sites <br /> Description(Make/Yrs, Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address r _ <br /> 2. ❑ PUMPER YARD/ V1 1' <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> i 3. ❑ .PERCOLATION TEST <br /> R.S..or R.C.E. Name R.S. or R.C.E. No. <br /> € f <br /> Testt L ation Test Date/Time <br /> 4. l!f SANITATION PERMIT /1 TM <br /> Job Address/Loc ti n ' <br /> Owner AdIf,ess< <br /> _f <br /> ❑ SEPTIC TANK ❑ CESSPOOL a LEACHING FIELD _, S�PAGE PIT ❑ PACKAGE PLANT <br /> ' ❑ PERMANENT ❑ TEMPORARY ❑ NEW C EPAIR ❑ OTHrER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 %� , <br /> i Type Construction Disposal Sitez <br /> No. of Units Equipment Storage/Cleaning Location(s).-\ 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June3019 <br /> Operator Name ( Where'Certified <br /> } 1 fLy <br /> Plant Location <br /> Plant Capacity ) No. Units Served*. 'r <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 /> f ordinances,-state laws, and rules and r lations of the Saji4aquip Local Health District. ; <br />` APPLICANT'S SIGNATURE X �- <br /> i <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J nuary 1 8 i/.,B,January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTA CE $ - <br /> BASE EXPLANATION PATE pAT REMITTED AMOUNT DUE CHFC1(ED <br /> AMOUNT <br /> FEE 5r 5r <br /> LESS <br /> PRORATiON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Puti <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E`HAZELTON AVE„P.O.Box 2009 ' STOCKTON,CA 95201 j <br />- i <br />