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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION I <br /> (For Non-Translerable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> ApplicationsI hereby,.made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Nam BA) Address <br /> r ~ 1� Address - - <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 6 �� + a Emergency Telephone No. <br /> Z�2_LContractor Licence No. t,- <br /> 1. <br /> Applicants Name (Print) Ered <br /> itle DatePlease check Applicable Cry (1-7) in the R �ormation <br /> j ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } <br /> f For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 <br /> Serial No. t CAL. License No. CAL. License Renewal,No. ^� <br /> Capacity Gal., Weights & Measures No. . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <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. <br /> Tesi�cation Test Date/Time <br /> 4. `ID SANITATION PERMIT <br /> Job Addres /Locati <br /> Owner <br /> Address <br /> S� e <br /> ❑ SEPTIC TANK 13CESSPOO ❑ LEACHING FIELD SF1__PAGE PIT 11 PACKAGE PLANT <br /> ' ❑ PERMANENT 11 TEMPORARY 11 NEW VRREPAIR ❑ 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 l n <br /> f[ Operator Name I Where Certified �J ) <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 have prepared this application and that the work-will be done in actor San Joaquin County <br /> a <br /> ordinances, state laws-.' rulesd gulatio he San Joaquin Local Health Dis c . <br /> APPLiCANT'S SIGNATURE X <br /> i4pC—� ff <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE, REMITTED AMOUNT <br /> FEE 41 <br /> LESS r <br /> ` PRORATION <br /> PLUS f ' <br /> PENALTY - - <br /> � C <br /> OTHER j Y , <br /> OTHER <br /> 41ssanL <br /> Received by Date Receipt No. ermit No. te Dae . Mailed Delivered <br /> APPLICANT—RETURN ALL"COPIE$TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E-HA ELTON AVE.,P.O.Boa 209 STOCKTON,GA 95201 <br />