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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. <br /> APPLICATION ,. <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r LIQUID WASTE <br /> Application is hereby made to car on burin in th j isdictional area of tf an Joaquin Local Health District <br /> hBusiness Name (DBA Address <br /> aOwner,E Address <br /> J Firm Partners, Addresses a T lephone Numbers <br /> ��a' _ Emergency Telephone No. <br /> CL Business Telephone No. <br /> a Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information f <br /> 1. ❑ PUMPER VEIHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites r <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. ❑ PERCOLATION TEST a T <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER Taj <br /> Job Addre s/ oc tion Q <br /> Address <br /> Owner . <br /> ❑ SEPTIC TANK E] CESSPOOL LEACHING FIELD )K SEEPAGE PIT QPACKAGE PLANtl <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site _ <br /> L No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r- <br /> Operator Name l Where Certified <br /> Plant Location <br /> >� Plant Capacity a 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 /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> . I hereby certi t have prepared t is applicati nand that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, rules and r e S 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEF LA <br /> LESS n <br /> PRORATION 2 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2 1.;, - <br /> Received by Date Receipt No. Permit No. lissuancq Dam Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />