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-.._ <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. � <br /> APPLICATION <br /> ' (For Non-Translerable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH!,ERMIT <br /> LIQUID WASTE <br /> Application is a de to car o b ss' the jurisdictional area oftheSan Joaquin Local H Ith District , <br /> Add ress.z <br /> Business Name .( ) - <br /> @ Address. 00 <br /> ! <br /> z Owner _ _. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. Emergency Telephone No. ' <br /> Contractor Licence No. � - <br /> Title, Date <br /> Applicants Name (Print) <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) CAL. License Renewal'No. <br /> .Serial No. CAL. License No. w w E <br /> N' <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 m <br /> 3 ] <br /> No. of Chemical Toilets Stored i <br /> 3: ❑-PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No _ v <br /> Tr —Test baie/Time <br /> est L cation <br /> 4.A,ANITATION PERMIT e <br /> Job Address/Loc on <br /> Owner r Address <br /> EPTIC TANK ❑ CESSPOOL ❑:LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT i <br /> LJ PERMANENT <br /> ❑ TEMPORARY �- <br /> NEW EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) �� w. <br /> 4 6. ❑ PACKAGE TREATMENT PLANT For July 1,--June 30, 19 s Where Certified <br /> Operator Name <br /> Plant Location <br /> k Plant Capacity g No. Units Served ; <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ) , <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ) <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Hereby certify that I have prepared this a plicatio and that the work`Will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and r u1 ions of a San quin Local Health Distric <br /> Ir _ . <br /> APPLICANT'S SIGNATURE X f <br /> e 4 . <br /> .� <br /> " •... .M..-.:.-- FOR DEPARTMENT USE ONLY t ;. <br /> - f i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT; El PER <br /> SITE s ❑ EACH ,❑ January 1 &Received By January 31, July 1 $Received$y July 31 <br /> REMIT <br /> ` 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i BASE EXPLANATION - DATE DATE REMITTED- - -�trp ;- AMOUNT <br /> '� -�y r '. - �-•- iF�tin.J+r e:eJpi...`a!- rw-,....-:1.._'[.... �• -M - . <br /> FEE <br /> a <br /> LESS <br /> PRORATION <br /> PLUS _ r .. ._ - - - - - - _,:t <br /> - <br /> PENALTY F q <br /> OTHER <br /> Received by Date Receipt No. - Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAVE.,P.O.Box 2009 STOCKTON,'CA 95201 <br />