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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 /> Application is eb adeto on us" ess in the jurisdictional area of the San.Joaquin Local Health Distri t <br /> yBusiness Name BA) . Address <br /> 4 Owner- wv Address <br /> Firm Partners, Addresses and Telephone Numberg <br /> CL Business Telephone No. r (• Emergency Telephone No.. <br /> Contractor Licence No. --- <br /> Applicants Name (Print) Title." DateOF <br /> r T <br /> Please check Applicable Category (1-7)and Fill inahe Required Information ,; # <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C�Z <br /> For July 1,- June 30, 19, " Disposal Sites - - —r <br /> Description(Make/Yr., Color) r <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 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4, ❑ SANITATION PERMIT/ <br /> Job Address/Location <br /> Owners Address C- - <br /> ❑ SEPTIC TANK ❑ CESSPOOL VLEACHING FIELD .94EEPAGE PIT " ❑ PACKAGE PLANT + <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW P11: EPAIR ❑ 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. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name M..._ Where Certified <br /> Plant Location r <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> V <br /> hereby certify that I have pre his app'cation nd that th 'wo-rk"Guill 'be done in accordance with San Joaquin County <br /> 1.1 �,_. <br /> ordinances, state laws, and d regu ons an Joa in Loc ealth 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 By July 31 <br /> REMIT <br /> rBILLING REMITTANCE $ <br /> BASE EXPLANATION DATE -- -DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT + <br /> E a <br /> FEE " - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER eLC�4 <br /> OTHER <br /> - <br /> Received by Date Receipt No. errrit No ssuanc D [e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES" - 1601 E.HAZELTpN AVE.,P.O.Box 2009 STOCKTON,CA 95201 t <br />