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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y - <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Aand 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 He Ith District m,ry <br /> Business ame(DaNAddress <br /> z Owner <br /> Address <br /> Z Firm Partners, Addresses and Telephonelumbers Y <br /> CL <br /> Business Telephone No. � � � <br /> � 7r" _.Emergency Telephone No- w <br /> f Contractor Licence No, <br /> Applicants Name (Print) - Title <br /> Date "'— <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, T9 -4Disposal Sitesr <br /> Description(Make/Yr., Color) <br /> Serial No. fCAL. License No. ---CAL. License Renewal No. <br /> Capacity Gal., Weights& Measures No. v <br /> Equipment Parking Address. <br /> 2. ❑ PUMPER YARD 4— <br /> For <br /> —For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I ?" I1 ..=. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _•R.S. or R.C.E. No. <br /> Te t Location Tesh•Date/Time + <br /> 4. SANITATION PERMIT <br /> Job Address/Locatio 09 F <br /> Owner Address -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD RREPAI <br /> EEPAGE PIT •❑ PACKAGE PLANTt <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW• R —tt-, -OTHER-- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19' <br /> Op <br /> Type Constructions Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT'PLANT For July 1, -June 30, 19 'w <br /> Operator Name . Where Certified'. <br /> Plant Location ) ".. _.�--- •— -. . <br /> Plant Capacity ) No. Units Served <br /> 7. ❑ LAUNDRY For July.1;-`June 30, 19 ! <br /> t , <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More-Than 1,000 Sq. FL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo 1 i <br /> I hereby certify tha[ I have prepared this application and that the work will be done in accordance h Jgn�t n 1 <br /> ordinances, state laws, and les and regula n�oftSan Joaquin Local Health District. <br /> tRI i <br /> APPLICANT'S SIGNATURE X <br /> r <br /> x FOR DEPARTMENT.USE ONLY jr <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received B g <br /> Y'January 31 ❑ July 1 &Received By July 31 <br /> I ' BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE GHECKED <br /> DATE DATE - REMITTED <br /> •.". a AMOUNT <br /> FEE- <br /> LESS <br /> EE- ,y/ <br /> LESS <br /> y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Oat Receipt No. Permit Np. Issuance Dat <br /> Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1Gp1 E.HAZELTON A .Box 2009 STOCKTON,CA 95201 ' <br />