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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE" <br /> LIQUID WASTE <br /> Application is hereby1fi2Veto carry o b mess in the jurisdictional area of the San Joaquin LOCAL.Heal i� t <br /> mBusiness Name (DBA Address <br /> z Owner Address <br /> a _ <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> -J Contractor Licence No. <br /> L Applicants Name (Print) Title a 4tw-1 Date <br /> Please 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.i CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures-No. ' <br /> Equipment Parking Ad1.dress <br /> 2. 11 PUMPER YARD�� 'k t T �� <br /> For July 1, June 30, 19 <br /> } <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 3 } <br /> R.S. or R.C.E. Name R.S. or R.C.E. No <br /> l. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT , <br /> Job Address/Location """" '�"��"� <br /> Owner17 <br /> T I Address <br /> ( SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ ERMANENT - ❑ TEMPORARYIJu <br /> NEW REPAIR" )' O I <br /> 5. ❑ CHEMICAL TOILETS For July 1, - a 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 /> Plant Capacity 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 /> . f <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 rule nd re ulations o h San Joaquin Lo al Ith District: <br /> 77 <br /> 4 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rec ived By January 31 ❑ July t &Received By July 31 <br /> _ - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Q O ) �d <br /> FEE N' �y <br /> LESS f AV <br /> i> PRORATION <br /> i - PLUS - - <br /> i <br /> PENALTY - <br /> OTHER <br /> I; I <br /> OTHER - <br /> Received by Date K Receipt No Per it No. - Iss ante D to Mailed Delivered Lc <br /> 'APPLICANT—RETURN ALL COPIES TO: •ENVIRONMENTAL HEALTH-PERMIT/SERVICES- 1601:E.-HAZELTON,AVE,,P.O.Boz 2009 -STOCKTON,CA 95201 <br />