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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppucaull <br /> APPLICATION <br /> s' -•^ (For Non-Transferable, Revocable, and Suspendable) 'f <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> �pplti h by m to ca on bu ss in the Mrisdictional area of the San �US cal aith flistri <br /> y Business ara '� Ad0ress <br /> f Address QS S` � <br /> a Owner <br /> Firm Partners, Addresses and Tel hone Numbers <br /> Business Telephone No. Emergency Telephone Na. <br /> Contractor Licence No. 1fCt ©�t <br /> Date- <br /> Applicants Name (Print) <br /> Title <br /> Please check Applicable Category(1-7)and Fill in the Required Iniormaillon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) i) CRL. License Renewal No. <br /> Serial No. CAL, License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD V�a <br /> For July 1, June 30, 19 w <br /> s No. of Vehicles Stored <br /> No.--6f Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location ,Test.Date/Ti me <br /> 4. X SANITATION PERMIT L3!� <br /> / <br /> Job Addre Locati In .� <br /> Owner Address r <br /> ❑ SEPT! 'TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACK E PLANT 1 <br />` ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> c <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i 6. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19 Where Certified <br /> Operator Name <br /> t <br /> Plant Location a <br /> Plant Capacity No. Units Served <br />� <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., (]� More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. \ E <br /> I re ared this application and that the work <br /> rk will be done in accordance with San Joaquin County <br /> I hereby certify that P <br /> ordinances, state la s, a les and regulati <br /> is of the n Joaquin Local Health District. .� <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑APER SITE 11 EACH ❑ January 1 &Received By January 31 E] July 1 8 ReceiveRdBy EMIITuly 31 <br /> - <br /> BILLING, REMITTANCE $ -AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE' REMITTED AMOUNT <br /> ' FEE r <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> Date Receipt No._ Permit No. I uance ate Mailed Delivered <br /> l - Raceiued by . <br /> [ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES,.,: .1601 E.HAZELTON AVE.,P.O.9ox.211�9 STOCKTON,.CA 95201 f <br />