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` Application_s Will.Be.Processed When Submitted Properly Completed.'Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ± Application is hereby made to carry on business in the-jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Address <br /> iOwner - G <br /> 4 Address <br /> - - <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. r Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title - Date—_ <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` l <br /> For July 1, June 30, 19 - 1Disposal Sites ' <br /> Description(Make/Yr., Color) f' ' <br /> Serial No. CAL. License No. ~^ CAL-L'Icense Renewal No. <br /> ,Capacity -- 'Gal.-, Weights-&-Measures No - - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD! r <br /> For July 1, June 30, 19 t y; <br /> No. of Vehicles Stored ' -s <br /> No. of Chemical Toilets Stored J � <br /> µ 3. ❑ PERCOLATION TEST I �. <br /> R.S. or R.C.E. Name <br /> Test Location R.S. or R.C.E. No. <br /> r Test Date/Time <br /> . I <br /> 4. ❑ SANITATION PERMIT r `; <br /> :+Job Address/Location / o _a`" <br /> �.;_,Ownef 17 <br /> I' Address '�/��J /f !'�► �. � C/u� <br /> , EPTIC TANK ❑ CESSPOOL LEACHING FIEL�' ❑ SEEPAGE PIT ❑ PACKAGE PLANT - <br /> ❑ PERMANENT ❑'TEMPORARY ❑`NEW ` •❑ REPAIR --- - ❑ OTHER ` =�� , . r <br /> 4. L ` s C <br /> 5. 4❑ 6kIEMICAL TOILETS For July 1,-June 30, 19 ' <br /> Type Construction - -'� F' ) � Disposal Site <br /> No. of Units Equipment Storage C eaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 <br /> _ Where Certified - <br /> Operator Name �--�- _ ; + <br /> Plant Location <br /> Plant Capacity ; `'' - No. Units Served ` <br /> 7. ❑ LAUNDRY For,July-1, -June�$0 19'• <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More—Vh-a 1,000 Sq. Ft. t le , <br /> ElDRY CLEANING, Chemicals Used/Amount/Mo. <br /> l hereby certify ithat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ��ordinances, state laws, and rules and regulations of the San'Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY . 0,PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received By January 31 ❑ July-t &.Received By July 31 <br /> 4/REMIT <br /> ' !BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE - 7 REMITTED - t AMOUNT <br /> I - <br /> FEE C <br /> LESS } <br /> PRORATION <br /> PLUS f1 eIU <br /> PENALTY <br /> ¢ OTHER <br /> . - Received by - Date Receipt No: ._... Permit No. :b .ate Mailed Delivered K, <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />