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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppllcanon. <br /> APPLICATION <br /> ` (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application here y made to carry on business in the jurisdictional area of the Joa Loil alth pqrict <br /> Business a (DBA) '� Address ' <br /> aowner C.Gl� _Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 3 .j Emergency Telephone No. <br /> a Contractor Licence No. <br /> LApplicants Name(Print).��qor <br /> ���Rqulredlformmln DatePlease check Applicable Ca1 7}-and-Fill in t <br /> 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. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 f <br /> No. of Vehicles Stored I <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 <br /> 4. ❑ SANITATION PERMIT r7 7 � / <br /> Job Address/Location E—® <br /> Owner Address ' <br /> 11SEPTIC TANK ElCESSPOOL ELEACHING FIELD 9;i-SEEPAGE PIT ❑ PACKAGE PLANT LA� t <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 2-REPAIR ❑ OTHER j <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 No. 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 /> I hereby certify that I have pre d this ap 'cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es regu of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> F <br /> ue: 13 ANNUALLY El PER UNIT ❑ PER SITE 11 EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ,yt AMOUNT <br /> �5 `� <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No I suance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />