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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 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUI6 WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N 9usiness Name (DBA) Address } <br /> Z Owner u Address �OC �' G vu,- <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> -J Contractor Licence No. <br /> �Applicants Name(Print) ' 'J'�T Title Date ' <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) .J <br /> For July 1,- -:- June 30, 19 Disposal Sites <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 r <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. r <br /> T2§LVcation Test Date/Time <br /> 4SANITATION PERMIT <br /> Job Address/Location 2-C,04- , /tai <br /> _.01&ner 'l - Ad ress r ❑ <br /> SEPTIC TANK C] CESSPOOL ACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY EW +❑_ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction a Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 d <br /> Operator Name Where Certified <br /> Plant Location j <br /> _ o <br /> Plant Capacity s No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19f 'l O <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County , <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX — <br /> r T � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received By Ju$y 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE GHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 4s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER J� <br /> .OTHER <br /> Received by Pate Receipt No., Permit No Issuance Date iled Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTONAV P ox 2009 STOCKTON,CA 95201 <br /> i <br />