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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> APPLICATION , <br /> r (For Non-Transferable, Revocable, and Suspendabie) x <br /> f SEPTAGE <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional Address <br /> area of th San J aquin Local Health District 2 <br /> F Business Name (DBA) <br /> Owner <br /> a Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 11 <br /> aBusiness Telephone No. 4 Emergency Telephone No. <br /> Contractor Licence No. 4 f yr <br /> Title Date — <br /> �Applicants Name (Print) <br /> Please check Applicable Category (1-7) and FIN in the Required Information �{ <br /> {1. ❑-PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -, -'- <br /> I� For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> CAL.,License No:�?�i -�=��'�- CAL. License Renewal No. <br /> .Serial No. - ^ <br /> Capacity Gal.,Weights B*Measures`N0 - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ` <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> t <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test L05-01. n Test Date/Time <br /> 1 <br /> 4. SANITATION PERMIT <br /> Job Address/Location 8 <br /> Owner l�l Z- C �°r- Address <br /> 0� . <br /> 15EPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑PERMANENT ❑ TEMPORARY ❑ NEW 53-'TFEPAIR ❑ OTHER --(11 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,19— <br /> Type <br /> 0, 19Type Construction . Disposal Site <br /> 1 No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served 4 <br /> 1 7. ❑ LAUNDRY For July 1, -June 30,.19 <br /> r, SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo- <br /> i r <br /> i I hereby certify that I h e prepared this application and thatAhe work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d uIes and gulations o h San J uin Local Health District. <br /> � APPLICANT'S SIGNATURE W'� <br /> I <br /> FOR DEPARTMENT USE ONLY ' <br /> r <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE 7 ❑ EACH ❑ January 1 &Received By January 31 El July 1 8 ReceivedREMIT my 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE -'EXPLANATION DATE PATE REMITTED AMOUNT <br /> S � <br /> ;,FEE . <br /> LESS I / <br /> PRORATION y d`t7 b <br /> PLUS <br /> PENALTY <br /> OTHER �ox— <br /> OTHER <br /> 1 <. <br /> r <br /> 1 uan at Mailed Delivered <br /> Received by Date i Receipt No: •� Permit <br /> APPLICANT—RETURN ALL COPIES TO: T ENVIRONMENTAL HEALTH-PERM % 1501 E.HAZEL E.,P.O.Box 2009 STOCKTON,CA 95261 <br /> I <br />