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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - s APPLICATION <br /> (For Non-TransfArabW,74evocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Appl icatio er made to c r on�sin in the jurisdictional area of the -San oaquin Lo aLHe District.. <br /> to Business Name BA) -0. ✓ Address <br /> z Owner .: :. .,.Addresss�J��- '. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. . <br /> L Applicants Name (Print) <br /> Please check Applicable Category 1-7 and Fill in the Required Information.y + V1 <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. \ n <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 R.C.E. Name R.S. or R.C.E. No. 4 t <br /> Test Location Test Date/Time �•1 <br /> 4. 0 SANITATION PERMIT <br /> Job Addre Tation Lrr r <br /> Owner I Address <br /> ❑ SEPTIC 4NK ❑ CESSPOOL ;2�- EACHING FIELD 9,55EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW - firREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - r <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 Where Certified <br /> Plant Location I <br /> .Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, --June 30, 19 ry <br /> SIZE: ❑ Less Than 1,000 Sq._Ft.,.a ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo- <br /> K <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 ru a d regulations f the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X- I + <br /> r <br /> 4- <br /> 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION _ AMOUNT DUE CHECKED <br /> ' DATE DATE - - REMITT AMOUNT <br /> FEELESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> 4 <br /> OTHER <br /> X.- <br /> Received <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 <br />