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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 i ereby made to carry on business in the jur' dictional area of the San Joaquin Local Health Distric <br /> y Business Name BA) a <br /> f Address 7 <br /> Owner 1 Address <br /> Firm Partners, Addresses and Telephone Num rs <br /> a Business Telephone No. ` b J/ Emergency Telephone No. <br /> Q 1 <br /> Contractor Licence No. 2 Z <br /> L Applicants Na (Print) Title _`A -3 Date <br /> me ®r <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 1 <br /> F <br /> Description(Make/Yr., Color) <br /> Seriai No. i CAL. License No. CAL. License Renewal No. <br /> a <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 /> k <br /> No. of Chemical.Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location fiTest=Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location Z 3 El' �•� if> =°`�'' s- ` <br /> Ow: <br /> w erL -� Address <br /> EPTIC TANK ❑ E55POOLCHiNG FIELD SEEPAGE PIT07PACKAGE PLANT <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 Equipment Storage/Cleaning Location(s) f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' p <br /> Operator Name Where Certified r� <br /> Plant Location t <br /> Plant Capacity No. Units Served <br /> 7. El LAUNDRY For July 1, -June 30, 19 f t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq4 Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accor a�je0 with San Joaquin County <br /> ordinances, state laws, and rule �n regulations of San Joaquin Local Health District. 1 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ Janua eceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING R ITTAN <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED <br /> C/n}� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> u at <br /> Received by Date Receipt No. Permit No. Issue ce Date Mailed Delivered ' <br /> APPLICANT-RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON'AVE.,P.O.Box 2009 STOCKTON,CA 95201 Fr <br /> 1 <br />