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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 /> LIQUID WASTE <br /> Application is her y made arty ons mess in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) .L c- Address <br /> z Owner Address <br /> C <br /> cJ Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. Z <br /> a <br /> -J Contractor Licence No. <br /> L Applicants Name (Print) Title _ A 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. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i i �`, g <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored krt , 2 <br /> No-of Chemical Toilets Stored <br /> s <br /> 3. 0— <br /> PERCOLATION TEST _ k f ; - ,' <br /> # . �, t R'S. or R.C.E. Nod• <br /> R.S. or R.C.E. Name , 1 _ _ - - <br /> Test Location R ' Test Date11"_irne <br /> 4. ❑ SANITATION PERMIT # ) (' . <br /> Job Address/Location `� � � '` - <br /> OwnerN 06h e us QhLpS ` I Address /L { <br /> ❑ SEPTIC TANK ❑ CESSPOOLEACHiNG FJ'E-E5 r❑,, �SSEEE�EPAGEPIT 11 PACKAGE PLANT <br /> ❑ PERMANENT; C3 TEMPORARY 11 NEW <br /> �►''t �rrFitf'AIR ❑ OTHER_ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,119 , <br /> Type Construction Disposal Site - <br /> No. of Units Equipment.Storage/Cleaning J Q.-q ior0),- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.1, -June 30,�19� " <br /> Operator Name ' ) Where Cerfified <br /> Plant Location � � �ti - � �-` ( -'� �" � � �*i•` <br /> Plant Capacity I € NO.Units Se ved <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 /> 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 regotloW of the San Joaquin Local Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:.El ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE � EXPLANATION DATE - DATE REMITTED AMOUNT DUE CHECKED <br /> ' f AMOUNT <br /> FEE "Ir <br /> f L{ <br /> LESS t+ /7NBI <br /> PRORATION w' <br /> PLUS <br /> PENALTY ;.. <br /> OTHER <br /> OTHER <br /> Received by Date' Receipt No. f` .A Permit No. i �, � Jssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �! 1601 0 <br /> .HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />