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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAppucauon. 1, <br /> I <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her made to carry business in the jurisdictional area of the San Joaquin Local Health District <br /> Addressf <br /> yBusiness Name (DBA) <br /> a Owner <br /> Address <br /> J Firm Partner , Ad res s and Telephone mbers Emergency Telephone No. <br /> a Business Telephone No. <br /> 4 i <br /> Contractor Licence No. Date <br /> Title <br /> �Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information. _ f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> CAL. License No. � � . -. CAL. Lic.�Lse Renewal No. <br /> Serial No. — NIX -114 <br /> Capacity Gal.,Weights & Measures No. ` <br /> "^ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 9 <br /> No. of Chemical Toilets Stored -. <br /> 3. ❑ PERCOLATION TESt ,....�..., ._ R.0 NcI. <br /> R.S. or R.C.E. Name t i <br /> ! =t1Test,,Date/Time ' <br /> Test Location i q <br /> 4. ❑ SANITATION P e <br /> Job Address/Location , <br /> Owner s Address <br /> ❑ CESSPOOL: EACHING FIELD SEEPAGE PIT 1:1 PACKAGE PLANT <br /> SEPTIC TANK I <br /> ERMANENT 11 TEMPORARY <br /> NEW - REPAIR f OTHER I <br /> 1 5. ❑ CHEMICAL TOILETS For July 1, -Ju a 30, 19 <br /> bisposaKsite <br /> Type Construction -� <br /> I Equipment Storage/M1Clearling Location(s) <br /> No. of Units <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> i <br /> f - , Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, - <br /> Jun 30, 19 <br /> i> SIZE: El13, <br /> Less Than 1,000•Sq. Ft., ' More Than 1; 5q.000^ Ft. <br /> �..o y <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mol <br /> f <br /> k I hereby certify that 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 regulatiothe San Joaquin Local H alth District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 E] July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE' EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS / So <br /> PRORATION r <br /> PLUS <br /> PENALTY _ ��,.t'. •-I. <br /> OTHER <br /> OTHER <br /> D 1-6-yo <br /> Delivered <br /> Date. ' Receipt No- Per N . Issuance Date Mailed <br /> Received by - 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> F APPLICANT—RETURN ALL COPIES TQ:� ENVIRONMENTAL HEALTH PEHMITISERVICES - t . <br />