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,� ...... <br /> Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br />" LIQu10 WASTE <br /> Applicatio ' hereby ma terry o b ines�jn 1e����i jurisdictional area of the San �a�uin Local Hea h D i t PT <br /> '7"' Jam ' Address /J <br /> OFBusinessName (DB ) © ,L T <br /> z Owner L' Address <br /> 4 <br /> 5 Firm Partners, Addresses and Telephone Numbers <br /> C6 <br /> Business Telephone No. -- ar°�� Emergency Telephone No. Q <br /> Contractor Licence No. s ; Date —le—; <br /> L Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites t <br /> Description(Make/Yr., Color) CAL. License 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. 11 PERCOLATION TEST '1'ai' <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name ~, <br /> Test Location �y4. Test Date/Time <br /> 4. gSANITATION PERMIT A01 ZW 7-5 <br /> Job Addr ss/Location PL <br /> Owner e LL S Address <br /> SEPTIC TANK 13 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKA E PLANT <br /> PERMANENT ❑ TEMPORARY NEW <br /> 11REPA�IR�` •MOTHER` <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 -!.�i Vt ' , <br /> Type Construction • Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location - C <br /> No. Units Served <br /> Plant Capacity <br /> k <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. ' R <br /> 1 <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, a es and regulati ns of the San Joaquin Local Health District. y <br /> APPLICANT'S SIGNATURE X .A <br /> r <br /> FOR DEPARTMENT USE ONLY /IF <br /> f + <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By danuary,31 ❑ July 1 &Received By July 31 <br /> y -S, REMIT <br /> r BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATIONREMITTED <br /> DATE DATE AMOUNT <br /> FEE <br /> LESS w <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. P r it N - Is uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES�,J801 HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />