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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,..,r Non-Transferable, Revocable, and Suspendabtww SEPTAGE. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application: herb made t ry �67 in the jurisdictional area of the a in Lo al Health str ct <br /> NBusines ame DBA) Address <br /> i Owner r <br /> a <br /> L) Firm Partners, Addresses and e a Nu ers _ <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> a 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) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <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 <br /> 3. ❑ PERCOLATIONTEST t <br /> RC 2 <br /> R.S. or R.C.E. Namem�l R.S. or R.C.E. No. <br /> Test Location Test Date/Time2P N7 - <br /> 4. ❑ SANITATION PERMIT S�� <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity _ _ — No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑, Y NIVV,Chemicals Used/Amount/Mo. <br /> In elle;t±nsrdacont't;signatueserrnfiesthelono t <br /> on!r ntAnraera5totreepmt sub_ oi)t 16 <br /> �rcmtrr=cc,alµersartl?r ;;,��P�p ,�t tinfh�perf rmancecf;;erc;kfcr;rhichthis parmitisissueVshallnot employ any person <br /> employ <br /> c`ar's Ni tiuli or sa0-cofltesC whi ,, tcre c�rt;1,;;5 tatic!arca; !certify that in the performance of the work for vihich this permit is issued,I shall <br /> employ persons sutllecl t>D tvVprktt>,t,'s C6trit a�tltz*I iatirs of Lali _ .. <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 the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />