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.. , T <br /> om <br /> Applications Will Be Processed When Submitted Properly <br /> I APPLICATION <br /> (For Non-Transterable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i erebY made carry on business in the jurdictional area of the San Joaquin ocal I �th�istrict <br /> �� Address <br /> mBusiness Name ( A) Address <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL <br /> Business Telephone No. 0 <br /> j Contractor Licence No. �. Title Date (� <br /> j a <br /> L Applicants Name (Print) 1J' <br /> in the Required Information <br /> Please check Applicable Category (1-7)and Fill <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License No. CAL, Lic-�se Renewal No. <br /> j Serial 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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time -� <br /> ° Test cation <br /> 4. ZSANITATION PERMIT p y1 <br /> Job Address/Loc tion C C Address �"" IP <br /> Owner �EACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> (�Y,/EPTIC TANK ❑ CESSPOOL 11 REPAIR <br /> 11 OTHER <br /> C <br /> LYPERMANENT ❑ TEMPORARY 500NEW <br /> 5, El CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site <br /> I Type Construction <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> 1• 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> I 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> F SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> t ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I , <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rules aW regulations of the San Joaquin Local Health District. <br /> e <br /> i APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> c <br /> PER UNIT �PER SITE EACH ❑ January 1 &Received By January 31 ❑ 3uly t &Received By July <br /> 31 <br /> Feels Due: ❑ ANNUALLY ❑ REMST <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> y l y z� <br /> i FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER G1 ZR c7 t J 7 / <br /> / 1issuance Date Mailed De4ivered <br /> Receipt NO. Permit No. <br /> Received by � Date 7605 E.HAZELTON AVE.,P.O.Box 2009 $TOCKTON,a 95201 <br /> �7 <br /> -. S TO: ENVIRONMENTAL HEALTH PERMITlSER� <br /> APPLICANT=RETURN ALL COME <br />