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tiebure io;wyll 111w <br /> Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION <br /> ` (For Non-Translerable,Revocabie,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application ereb X11 e to carryon bu ess in thefjurisdictional.area of the San Joa urn Local h <br /> yBusiness me(DB ) ` Address <br /> ` Owner — - Address I <br /> Firm Partne s, Addresses and Te ephone Number r <br /> E Business Telephone.No.. = Emergency Telephone No. I <br /> 4 �.� ..i <br /> i -j Contractor Licence No. Date <br /> ApplicantsF Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill in the equlred Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> j For July 1,'—June 30, 191. - - Disposal Sites I <br /> ' Description(Make/Yr.,Color) ; <br /> I CAL. License Renewal No. <br /> Serial No. CAL. License No. I <br /> Capacity Gal., Weights & Measures No. I i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored " <br /> ( No. of Chemical Toilets Stored <br /> f 3. ❑-PERCOLATION TEST f s'' <br /> R.S. or R.C.E. Name R.S.or R.C.E�No: ' <br /> i Test Location Test Date/Time <br /> 4. ❑ SANITATION PER ITt+ <br /> Job Address/Locat' <br /> Owner ❑ PACKAGE PLANT <br /> Address `I <br /> SEPTIC TANK �❑ CESSPOOL_ ❑ LEACHING'FIELD 11 SEEPAGE PIT <br /> '_ q <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER <br /> °, 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units ''I ' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT,.PLANT For July 1, -June 30, 16'.. . <br /> Where Certified <br /> Operator Name i - <br /> .F <br /> ng <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> r F. <br /> 7. 0 LAUNDRY- For'July 1, June 30, 19 <br /> ti <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft:, <br /> f ❑ DRY CLEANING,Chemicals Used/AmOunt/MO. <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, an and regulations of the quip Local Health District. I <br /> APPLICANT'S SIGNATURE X <br /> - r__(_ a <br /> 1f FUR DEPARTMENT USE ONLY.._ ' <br /> Ir Fee Is Dile: El ANNUALLY., ❑ PER UNIT -❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION ,BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE 'REMITTED AMOUNT „ <br /> FEE <br /> LESS — <br /> PRORATION <br /> PLUS <br /> • <br /> PENALTY- <br /> OTHER <br /> ENALTY'OTHER 3 <br /> i <br /> } - .i <br /> vv <br /> - Received by Date Receipt No. Permit No - Issuance Date ailed Delivered <br /> i... I <br /> APPLICANT—RETURN ALL;'COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 20o9 STOCKTON,CA 95201- <br />