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" APP11catlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> #: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I <br /> LIQUID WASTE ' <br /> AppiicatI h eby e to rry on business in the jurisdictional area of the San agsain al He s ct <br /> w Business Na a (DBA) Addre ` <br /> ' _ Owner 1 Address <br /> a I <br /> k : Firm Partners, Addresses and Telephone Numbers <br /> r a Business Telephone No. �4 e/ - Emergency Telephone No. <br /> a <br /> _J Contractor Licence No. r- <br /> Applicants Name (Print) + Title Date <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) <br /> ' CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> j Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> f 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. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. /Wf^ SANITATION PERMI _ <br /> Job Add r s/Lo tion <br /> O ner <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SK SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 1F NEW ❑ REPAIR ❑ OTHER <br /> 5. 1] 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 /> 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 /> 1] DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> x <br /> I hereby certify that I h prep d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, nd rul re ulations o the San ijiIfaquin Local Health District. <br /> A <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> 2 <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar ' ❑ July,1 &Received By July 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMO NT E CHECKED <br /> BASE EXPLANATION - <br /> �. DATE DATE R MITT AMOUNT <br /> FEE <br /> LESS <br /> + I <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4 <br /> Received by Date Receipt N07 Permit No. Issuance Date . Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES - 16D1.E.HA2ELTON AVE.,P.O.Boa 2009 '.STOCKTON,CA% r <br />