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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheAppucalnon. <br /> -" APPLICATION <br /> .' (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> l LIQUID WASTE <br /> Application is hereby de car on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) Address , <br /> eOwner : .:Address . <br /> l u Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. w <br /> Contractor Licence No. F _ <br /> LAPPlicants Name (Print) Tit <br /> 1e {, -!Le �� Y i..,: - Date <br /> Please check Applicable Category.(1-7)and Fill in the Required Information <br /> f 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. �f <br /> P Y , <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19No. 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.G.E. No. <br /> Test Location Test Date/Time <br /> 4. E] SANITATION PERMIT �� <br /> Job Address/Location �c d r r ` v " <br /> Owner _ � 9 ✓` Address 1 <br /> VSEPTIC TANK ❑ CESSPOOL ®'ACHING FIELD ElSEEPAGE'"P1T•, 1:1 PACKAGE PLANT - <br /> ❑ PERMANENT' ❑ TEMPORARY ❑•NEW ❑ REPAIR '- ❑ OTHER <br /> ' 7 <br /> S. ❑ CHEMICAL-TOILETS . For_July.1,-June 30, 19 <br /> Type Construction Disposal Site . - <br /> No. of Units –r Equipment,Stoi•age/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> t <br /> Operator Name - Wht�e Certified <br /> ,f Plant Location \� : <br /> Plant Capacity No. Units Served ` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 4 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> =,s•.ri Vii;S' - - -< „� r : <br /> F 'I'he�eby 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 ancl-re7jlatens of he San Joaquin;Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> .. � <br /> ` + ' FOR DEPARTMENT USE•ONL-Y— <br /> Fee Is Due: ❑ ANNUALLY �❑ PER-UNIT �0-PER,SITE:,;1�.O EACH_` ❑-`January 1,&Receivetl.8y January 31 ❑ Ju#y 1 &Received By - 31 <br /> REMIT"� <br /> k BILLING --» REMITTANCE-�"- $. AMOUNT DUE CHECKED <br /> BASE EXPLANATIONREMITTED <br /> R-- ...�....��..x,-. DATE "DATE'- AMOUNT t, <br /> ea <br /> FEE , .i - - <br /> LESS ' <br /> * PRORATION <br /> PLUS <br /> PENALTY f `s �• -�"" - - - - - — - ..w.- <br /> 4 OTHER .i._.., / <br /> OTHER <br /> Received by Date Receipt No. Permit No. . ssu ce a Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '•- 1601 E.HAZELTO :,P.O.Box 2D09 STOCKTON,CA 95201 - <br /> F <br />