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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 p3 <br /> ­-ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ruslness Name (DBA) Address <br /> r <br /> N h <br /> aOwners Address x `Y 1 <br />/u Firm Partners, Addresses and Telephone lVmbers <br /> Business Telephone No. Emergency Telephone No. <br /> Q.\�Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> lease check Applicable Category(1-7)and Fill in the Required Information <br /> 1'� ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. Na. <br /> Test Loc n Test Date/Time <br /> 4r SANITATION P R <br /> Job Address/Location �T o/� Tpyr y3 Z� <br /> ner �° —7-Qlk /�f 4 Address <br /> /011w <br /> SEPTI TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑�.,,�PACKAGE PLANT <br /> `❑ PERMANENT ❑ TEMPORARY ❑ NEW 13 REPAIR �1d"OTHERpc <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 /> E 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 4 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 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 r ulations of the San 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 /> FEE _ 3 <br /> LESS Tr <br /> � PRORATION <br /> PLUSr <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ceived by ate Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 �, <br />