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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made t`carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) EMI/ ' Address �4 <br /> z Owner 41 !a'�G�(✓�- Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers CIA <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title 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 /> { <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 t <br /> I <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> Test Location :Test Date/Time <br /> 4. ❑ SANITATION PERMIT `( <br /> Job Address/Location <br /> �./� �,�r)t1 _ Address r <br /> Owner — � ,� � � t <br /> �aEPTIC-TANK <br /> CESSPOOL <br /> I-1LEACHING FIELD ❑ SEEPAGE"PIT ❑ PACKAGE PLANT r <br /> .❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C> <br /> Type Construction-- Disposal Site i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ` <br /> Ili Operator Name Where Certified <br /> 1 <br /> i Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY��For July 1, -June 30, 19 a'` ' it <br /> SIZE: ❑• Less Than 1,000 Sq.,Ft, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mc. = <br /> I' <br /> hereby certify that I' have prepared thieapplication and-that the worklwill be done in accordance with San Joaquin County <br /> ordinances, state laws,,and rules and regu ns. he_San_JoaquirT Local Health District. <br /> f <br /> APPLICANT'S SIGNATURE X T <br /> f f ` <br /> i f _ - — FO _DEPARN�L.YTMENTO _, <br /> .J <br /> Fee Is Due: ❑ ANNUALLY + ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July,t &Received By July 31 <br /> 1 REMIT <br /> I �- EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE DATE DATE REMITTED - AMOUNT <br /> FEE <br /> LESS ; <br /> PRORATION <br /> PLUS - -, •a.,_ i <br /> ' PENALTY <br /> 1 -a. :.,r' d-4'4�'L.Ems".., •t. -_` ;�, - <br /> OTHER -- <br /> Received by Date Receipt No Permit No. I suancei Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON-AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />