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Applications Will Be Processed When Submitted Properly Completed. Be ure ToSignTheAppucauon. <br /> - XPPLCATION <br /> (For Nan-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicativ I er made t ca ouslness In the jurisdictional area of thfIllan Joaquin L e s <br /> OF Business Name (DBA) Address <br /> I- Address <br /> zz Owner <br /> 41 <br /> J Firm Partners, Addresses and T p one l [nbers <br /> a Emergency Telephone No. I <br /> a Business Telephone No. <br /> Contractor Licence No. - <br /> �'� Title ' Date <br /> L Applicants Name(Print) Sl <br /> Please check Applicable Category (1-7)and Fill in the Required Information <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. <br /> Capacity - Gal.,Weights &Measures No. <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 / c <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 /> Test Location Test Date/Time <br /> ' 1 <br /> 4.SANITATION PERtyq r <br /> Job Address/Location ++--f� <br /> OwnerAddress <br /> .SEPTIC TANK 11CESSPOOL LEA ICHING FIELD 13-SEEPAGE PIT ❑ PACKAGE P4ANT - -. <br /> PERMANENT ElTEMPORARY 13NEW REPAIR +OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, '19 <br /> Type Construction_ ��. . Disposal Site -k <br /> No. of Units -� +Equipment`StoF.age/Cleaning Locations} <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 .. <br /> Operator NameWMere Certified. <br /> Plant Location <br /> Plant Capacity <br /> ` No. Units,Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 � ' r <br /> SIZE: ❑ Less ThV 1,000 Sq,.Ft:, ,-Z.❑.More Than 1,000 Sq. Ft. <br /> I <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMO. <br /> I <br /> I hereby certify that I have prepared this. licati nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru e f e n Joaquin=Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s-Due: ❑ ANNUALLY %<-11 PER UNIT ❑ PER SITE ❑ EACH +❑ January 1 &Received By January 31 o d July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REI41R ANCE $ -`'AMOUNT DUE CHECKED <br /> DATE t DATE REMITTED _ AMOUNT <br /> FEE 44 <br /> yFj <br /> LESS <br /> PRORATION r <br /> t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> P <br /> OTHER L <br /> Received by Date Receipt Na. �� Permit il, r,� .„� Iss nca..Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZE&oN AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />