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Applications Will Be Processed When Submitted Properly Completed. tiesure 1oalga ua�rr••��•••- <br /> APPLICATION ; <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby de to carry busines in the jurisdictional area of the Sa` aqui ocaI a th Di rict ' <br /> r Business a (DBA) AddressIf <br /> ry <br /> H Address <br /> a Owner E <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. �a"3 Emergency Telephone No. <br /> Contractor Licence No. /,3.-f/ , <br /> Title ���e-^ Date �, <br /> L Applicants Name(Print) Fe<L <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites LP <br /> Description(Make/Yr.,Color) CAL. Llccnse Renewal No. <br /> Serial No. CAL. License 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. No. <br /> R.S. or R.C.E. Name <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT _ <br /> (. .. ~ <br /> ec <br /> Job Addres ocation <br /> f- Ad ress S tfx" <br /> Owner 11 PACKAGE PLANT <br /> ER/SEPTIC TANK ❑ CESSPOOL LB <br /> EACHING FIELD B--SEEPAGE PIT <br /> BPERMANENT ❑ TEMPORARY G-NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment men <br /> E ui t Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 ap ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an s d regula f t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY C1 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By l July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CH KED <br /> DATE DATE REMITTED NT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. '�' lssuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC.K_TON CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES `fv/r !�/.J, <br />