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Applications Will Be Processed When Submitted Properly Completed. Be SureTo sign 1neAppllcausirl. <br /> 4" APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is hereb made to c on bu?lPess is the jurisdictional area oft oa in Locj�alth D' Pict <br /> yBusiness a (DBA) Addres <br /> a Owner <br /> gE Address <br /> 2 � Lzr �Firm Partners, Addresses and Telephone Numbers— E y5� <br /> aBusiness Telephone No. -3 Emergency Telephone No. <br /> Contractor Licence No. <br /> 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. r <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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT �PAC�KAGE <br /> Job Address/jryecation 1' 3SC �o, <. AddressOwner _ NT �-- <br /> 0 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD Ei SEEPnEPIT <br /> B-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 Loc <br /> ation{s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 1,004 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this applic9oun and that the work will be done in accordance with Sin J5 aquin County <br /> ordinances, state laws, and r s d regulation f e S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X j 4 <br /> FOR DEPARTMENT USE ONLY rAyry'') <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received B�J ry 31 ❑ July 1 &Received By JuVy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE i.� �� AMOUNT DUE CHECKED <br /> DATE DATE RE,MI ED AMOUNT <br /> FEE <br /> LESS is <br /> PRORATION <br /> PLUS <br /> PENALTY 9 <br /> OTHER <br /> OTHER 1 1"A <br /> Received by Date Receipt No. Permit No. Is� awn e e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2002 STOCKTON,CA 95201 . <br />