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TO bign onemppI160LIVII, <br /> Applications Will Be Processed When Submitted Properly"Comp ete aSure <br /> APPLICATION ' / <br /> "^ (For Non-Transferable, Revocable,and Suspendable) / SEPTAGE i <br /> '� ENVIRONMENTAL HEALTH PERMIT d <br /> .w <br /> LIQUID WASTE <br /> Application i ere y made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> Business Name (DBA) <br /> f Address <br /> I Owner <br /> a <br /> 1 Firm Partners, Addresses and Telephone Numbers i <br /> IL Business Telephone No. ;+ Emergency Telephone No. <br /> Contractor Licence No. id Date <br /> Applicants Name (Print) ��_ ���� <br /> Title <br /> Please check Applicable Category (1-7) and Fill in the Required Intormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. J <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. I <br /> i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. I <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. .V SANITATION PERMIT ' <br /> Job Address/Location <br /> Owner Address O(1 i <br /> PSI SEPTIC TANK ❑ CESSPOOL rUtLEACHING FIELD Z SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ TEMPORARY , NEW — ❑ REPAIR 11OTHER y) <br /> PERMANENT 1_ <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity -41 No. Units Served <br /> 7, ❑ LAUNDRY For July 1;'-June 30, 19' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑t More Than 1,000 Sq. Ft. Y <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> { <br /> 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 regulations of t n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By my 31 <br /> Fee IS DUB' ❑ ANNUALLY PER UNIT <br /> `BASE "EXPLANATION BILLING _ REMITTANCE AMOUNTOUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> M FEE <br /> JL5 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY ± <br /> OTHER <br /> I, OTHER <br /> I LAY <br /> :f J <br /> Date Receipt No. Perms o. Issuance Date Mailed De iv red <br /> t Received by 1601 E.HAZELTON AVE.,P.O.Box-2009STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES. .-- <br />