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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE y <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is a eby made to rry on bu ' ess i jurisdic 'onal area of the San Joaquin Lac Health Di riot <br /> HBusiness Name (DBA) Addr ss # <br /> aOwner Address- D <br /> Firm Partners, Addresses and Telephone Numbers <br /> d. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> � <br /> Applicants Name (Print) Title �� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, M "June 30, 19 - - - " Disposal Sites <br /> Description(MakeNr., Color)._ A <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity - 'Gal., Weights..&Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> :For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored i ?` <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. +$ANITATION PERMIT T �q75-,� <br /> Job Address/Location <br /> Owner edi� 4jm(4E— Address <br /> )—&--GEPTIC TANK ❑ CESSPOOL Re+-EACHiNG FIELD SEEPAGE PIT ❑ PACKAGE PLANT "14 <br /> PERMANENT ❑ TEMPORARY10-'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 <br /> Where Certified <br /> Operator Name <br /> Plant Location _ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f <br /> F SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home owna, n tj4vlh-�s�r.t5,pct, 'ricc *ter .^_,: this p rmitisissued,ishalln0iemp10yanypersGn <br /> r in sick nnclftt!E?? <br /> Contra^.�Y`E i Ff.1[t LSF sats- ar;B:erisreci r ss. . , _ t�'e work l-t is issued,I shall <br /> enp;ay i ersons sl ai�ct i2 r,°orkkrtan s tellipp:: _t?ie„iav,c u!f iii t:d <br /> I hereby certify that I have pre yd this applicatiori and that the work will-be done in-accordance with San Joaquin County <br /> ordinances, state laws, and r es d re ations o the San Joaquin Loc ealth istrict. <br /> y <br /> APPLICANT'S SYGNATURE'X - � <br /> FOR DEPARTMENT USE ONLY <br /> s a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 13EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 .I <br /> REMIT i <br /> BASE EXPLANATIONANCE $ _AMOUNT DUE CHECKED <br /> E FREMITTED AMOUNT <br /> FEE SC <br /> LESSPRORATIONPLUS <br /> PENALTYOTHEROTHER . <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />