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14,1- 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 /> Appl icatio I hereby made to;car on business in the jurisdictional area of t4psan Joaq n Local Health District <br /> NBusiness Name (DBA) I � Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and T,_eyye hone Numbers <br /> aBusiness Telephone No. '^l G bDr7 Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) Title ftArnm Date I <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 <br /> 2. ❑ PUMPER YARD <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 /> Testa Location Test Date/Time _ <br /> 4. x<SANITATION PERMIT r ,.�.r <br /> Job Addr? Ui<1cation a KK <br /> Owner _/V _;�52-ir.�b]►2 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL JCLEACHING FIELD K SEEPAGE PIT ❑ PACKAGE PLANT <br /> IKPERMANENT ❑ 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <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 I have prepared this application 5pdqhat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regula ' f t Sa J quin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECK <br /> AMO T / <br /> /yr- <br /> FEE ,a 's <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3a4 CL `t-B- � <br /> Received by Date Receipt No.. , Permit No. sua e D e ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.-kAZELTON AVE., 2009 STOCKTON,CA 95201 — - <br /> tiff�— <br />