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Applications Will Be Processed When SubAPPL`CAT1ONProperly Completed. <br /> e eBe <br /> v% a (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ct <br /> Application is reb made arry n business in the jurisdictional area of the San Joaquin L �Health D'istrir� <br /> e Address ! <br /> yBusiness Nam (DBA Address <br /> Il Owner <br /> a <br /> Firm Partners, Addresses a��elhonelur1 ers Emergency Telephone No. <br /> aBusiness Telephone No. G <br /> Contractor Licence No. -3 Title - Date <br /> L Applicants Name (Print) <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) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 + <br /> No. of Vehicles Stored <br /> 1 <br /> No. of Chemical Toilets Stored <br /> i <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT <br /> Job Address/Location Address <br /> Owner11PACKAGE PLANT Oi <br /> to SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11 REPAIR E PIT ❑ OTHER <br /> .PERMANENT C] TEMPORARY r&NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> Equipment Storage/Gleaning Location(s) <br /> No. of Units <br /> 0,19 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> t Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> Than 1,000 Sq. Ft. <br /> SIZE: EJ Less Than 1,000 Sq. Ft., 11 <br /> } 0 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify. <br /> that I have prepared this appl, tion nd that the work will be done in accordance with San Joaquin County <br /> ' ordinances, state laws, and r nd r ul of San J quip Local Health District <br /> I <br /> APPLICANT'S SIGNATURE X <br /> G _ <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> ❑ Jan ry eceived By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Dile: © ANNUALLY ❑ PER UNIT ❑ PE H SITE ❑ EACH REMIT <br /> BILLING REMITTAL � $ AMOUNT DUE CHECKED - <br /> BASE EXPLANATION ppTE Dg1F REMITTED RMOUNT <br /> I � h7 <br /> FEE <br /> LESS " <br /> PRORATION � - <br /> PLUS <br /> F PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> 43 rl Ll ` J <br /> Permit No, 16x1 E.I u e to Mailed Delivered <br /> € Received by - Date Receipt No. a AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br /> e H <br /> APPLICANT—RETURN ALL COPIES T� ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />