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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheA plication. i <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Address <br /> aOwner Address - - <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone,No. Emergency Telephone No. <br /> Contractor Licence No. i <br /> LApplicants Name (Print) Title. Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C� <br /> For July 1, June 30, 19= Disposal Sites <br /> Description(MakeNr., 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 /> . c <br /> For July 1, June 30, 19 k , <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 /> Test Location Test Date/Time r '` <br /> 4. j6 SANITATION PERMI i W . <br /> _Job Address/Location ®ate d I <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 1 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 5�3EP IR ❑ OTHER / f V" <br /> 5. 11CHEMICAL TOILETS For July 1, -June 30, 19 - /Y5 // 3 7S T/` L?�'H �.tiPs. <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 Na. 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 /> n �3• <br /> I hereby certify that i ve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, and rules and regulations of the$ Joaquin Local Health District. <br /> d <br /> APPLICANT'S SIGNATUR <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 <br /> BILLING REMITTANCE $ REMIT ; <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE PPTE REMITTED AMOUNT I <br /> FEE <br /> LESS y <br /> PRORATION - <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> Received by jDate :f Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 209 STOCKTON,CA 95201 - <br />