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` en SublRlitted Woperly Completed. BeSureTomign ineskppHuii2 U <br /> Applications Will Be Processed Wh <br /> APPLICATION ` <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the N jurisdictionalarea <br /> of the San Joaquin Local Health District Business Name (DBA) <br /> Address <br /> a Owner <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a. Business Telephone No. <br /> a <br /> Contractor Licence No. Date <br /> Title <br /> a Applicants Name (Print) <br /> Please check Applicable Category(1-7) and Fill in the Required Inlormation <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. <br /> Serial No. GAL. License 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 Stot:bd <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK 11 CESSPOOL 13 LEACHING FIELD ❑ SEEPAGE PIT 11 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 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ft��work hereby certify that I have prepared tis application wl be done in accorda ce with San Joaquin County <br /> ordinances, state laws, and rules and r gulati s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 4010 co <br /> FOR EPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &ReceiveRdEByl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> led <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date MaiDelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box n09 STOCKTON,CA 95 <br />