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Applications Ws"-=W-Processed When Submitted Property Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' er y ma ca usi in the jurisdictional area of the San Joaquin Loca e D' ri <br /> Business N e (D ) <br /> Add re Q Sr <br /> aOwner Address <br /> J Firm Partners, Addresses and Telono-Numbers 1 <br /> a Business Telephone No. �, Emergency Telephone No. j <br /> d <br /> � Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Req red Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc z5e Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> yl <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> j For July 1, June 30, 19 <br /> k ` <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. Na. <br /> Test Location A f Test Date/Time / <br /> 4. X-SANITATION PERMIT <br /> i Job Address! ation — <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL EACHING FIELD IrCSEEPAGE PIT ❑ PACKAGE PLANT <br /> r ❑ PERMANENT ❑ TEMPORARY EW .REPAIR ❑ OTHER s <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 /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> A ' <br /> I hereby certify that ! have prepared this application��t thq,wor will tie done in accordance with San Joaquin Couordinances, state laws, and rule regulations of thoaq,in L a Health District.APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &Received y Januar 35 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BRSE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> _ DATE DATE EMI T AMOUNT <br /> t__- - I_ n, (( ff <br /> FEE <br /> L T q <br /> _ LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY fr <br /> OTHER <br /> OTHER <br /> - i <br /> Received by Date •: Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALLCOPIESTO:r ENVIRONMENTAL HEALTH,PERMIT/SERVICES 1604 E.HAZELTON AY .Box 2009 STOCKTON,CA 95201 <br />