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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> j APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of t San Joaquin Local Health District <br /> O Business Name (DBA) �� p�T�t� �n'I� F - Address �� <br /> Address <br /> 4 Owner j <br /> Firm Partners, Addresses and Telephone Numbers <br /> d Business Telephone No. a Emergency Telephone No. <br /> a {� <br /> Contractor Licence No. }; 1_ Date ` <br /> Applicants Name (Print) t Title <br /> Please check Applicable Category (1-7)and Fill in the Required Information Z> <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <br /> For July 1, June 30, 19 Disposal Sites + <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. IN SANITATION PERMIT ell <br /> Job Address/Location ZZ,9 <br /> Owner 01 4A S Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 'Z LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 6- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW JU REPAIR ❑ OTHER (fl <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 —I-_ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> K <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San JoaquW Count <br /> i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f <br /> APPLICANT'S SIGNATURE X <br /> .rf"e, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITBy uiy 31 <br /> f BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I � soo <br /> y FEE � <br /> i` LESS t <br /> x PRORATION <br /> PLUS - <br /> PENALTY + <br /> OTHER <br /> OTHER • <br /> tss ance Dat Mailed Delivered <br /> Received by Date Receipt No. Permit No. <br /> 1501 E.HAZELTON AVE.,.P.O.Box 2009 STOCKTON,CA s62(& <br /> k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �- <br /> . r� <br />