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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> w F3 <br /> LIQUID WASTE F , <br /> Application i erepy made to cam on siness in t juris tional area of the Sa qu1 ocal Health District <br /> rn Business Na BA) � � Address � 767 <br /> z Owner Address <br /> a <br /> u Firm Partners, Addresses and T/elep one Numbe <br /> CL Business Telephone No. /� Emergency Telephone No. <br /> Contractor Licence No. :E <br /> Applicants Name (Print) Title bate <br /> Please check Applicable Category(1-7) and Fill in We Requi d Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites ` <br /> Description(Make/Yr., Color) 9 <br /> Serial No. CAL. License No. CAL. License Renewal No. I <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 J <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 L ation Test Date/Time r 1 <br /> 4. SAnn��NITATION PERMIT 1V J C� <br /> Job Addres ocation� <br /> t { <br /> Ow r Address <br /> TIC TANK ElCESSPOOL LEACHING FIELD 0"^tEPAGE PIT ❑ PAC AGE PLANT 1 <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER o , ' <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 W <br /> Plant Locationr <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/AmounVMo. <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, and rules and tions of the San J u' Local Health District. <br /> APPLICANT'S SIGNATURE X f <br /> t <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED/ AMOUNT <br /> FEE �y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY — -'- <br /> r <br /> OTHER I <br /> y <br /> OTHER <br /> ceived by Date Receipt No. Pert No. Issua c to - Mailed Delivered <br /> —RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> -le �� <br />