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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> a <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE v <br /> Application is ereby made to arty on bus ess in the jurl5 ctional area of the San Joaquin Local Health District <br /> mBusiness Name (DBS Address_�� �`` �� <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. d Emergency Telephone No. <br /> j Contractor Licence No. <br /> Title Date _ <br /> Applicants Name (Print) <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"` JuneF30'i9 Disposal Sites <br /> Description(Make/Yr.,Color) 0, it Renewal No. <br /> Serial No. — , _fi- _= CAL. License No. CRL LEccnse <br /> "e A- 4.4-A. &'i Gal!Weights &Measures No. <br /> Capacity I <br /> Equipment Parking Address -'' <br /> 2. 13 PUMPER YARD L <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ) <br /> No, of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> I R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name - <br /> Test Dation Test Date/Time <br /> 4. U SANITATION PERMIT 1.61 ' <br /> Job Address ocation <br /> O„�w,�er �-�'� ,.��X'L'eJ - Address ❑ PACKAGE PLANT N <br /> i� TIC TANK ❑ CESSPOOL C�YCEACHING FIELD ®` IT 13 OTHER <br /> Ic <br /> I L� PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction' Disposal Site <br /> t <br /> Sora a/Cleanin Locations <br /> No. of Units Equipment .�,.,.�gg-�-- ( ) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Where Certified ---------- <br /> Operator Name ; ` <br /> Plant Location I <br /> Plant Capacity I No, Units Served (D <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C1More Than 1,000 Sq.F t. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> el t <br /> j `I hereby-!certify-.that=-have'prepared._this:rapplication andYthat_the worker illi be done in accordance with San Joaquin County <br /> f ordinances, state laws, and rules nd regulations of the San Joaquin Local Hea4th District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Heceiv By January 31 ❑ July 1 &ReceiveRdEByl July 31 <br /> BASE EXPLANATION BILLING' REMITTANCE AMOUNT DUE CHECKED <br /> REMI ED <br /> DATE DATE AMOUNT <br /> FEE <br /> LESS 9- <br /> PRORATION <br /> PLUS I / <br /> PENALTY <br /> ! OTHER <br /> OTHER <br /> Received by Date Receipt No. Per it o. Issuance Date Mailed Delivered <br /> ' - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,, A 952 <br />