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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 /> W ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatio 's ereby made to carry on business in the jurisdictional area of the San Joaquin Loo Health District 01 <br /> + <br /> F Business N AAddress�-��._ �. <br /> z Owner Address <br /> J Firm Partners, Addresses and Te on N tubers <br /> R a Business Telephone No. `s" Emergency Telephone No. <br /> Contractor Licence No. . <br /> LAppl cants Name (Print) �� Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> I 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. 11 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> l�lo,of Chemical Toilets Stored <br /> 3.r❑'PERCOLATION TEST a <br /> RcS. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. XSANITATION PERMIT <br /> Job Address/Lo +o ��p <br /> wner Add res <br /> ` PTIC TAN!( ❑ CESSPOOL LEACHING FIELD : SEEPAGE PIT' ❑ PACKAGE PLANT <br /> SE ❑ OTHER <br /> PERMANENT ❑ TEMPORARY XNEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 OZ} <br /> Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> 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 /> I ❑ 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 Joaquiir, <br /> ordinances, state laws, aland regulations of the San Joaquin Loc Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑-PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received <br /> ByJuly31 <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUDUECKED <br /> DATE DATE REMITTED UNT <br /> 74 <br /> FEE S� 'T� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> tr OTHER <br /> OTHER <br /> 6W 613,S 7 <br /> Rec <br /> pate Receipt No. Permit No. Issuance Oat <br /> eived by <br /> Mailed,- Delivered.. <br /> APPLICANT—RETURN ALL COPIES TO: "ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Baa 2009�.iA STOCKTON,CA95201 <br />