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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The ApPlicatiort` ` <br /> APPLICATION <br /> I� (For Non-Transferable,Revocable,and Suspendable) '" SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is^he by madte�to�car o business in j Jurisdictional area of the�S.aan`Joaq I cal Health District <br /> FBusiness Name (DBA)1�ft�IV �-Lp Address <br /> a Owner Address <br /> L Firm Partners, Addresses and eIe hone Numbers-�� <br /> 3. Business Telephone No. R 1 Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print, 95 2W 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 /> Capacity Gal.,Weights&Measures NO. <br /> Equipment Parking Address r <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test L cation Test Date/Time <br /> 4, SANITATION PERMIT <br /> Job Address/Location <br /> e---) <br /> Ow er --V�—�.L'L� <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD )<SEEPAGE PIT ❑ PACKAGE PLANT <br /> jg!NPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 CP <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 /> I hereby certify that I have prepared t a l.icat on and that the work will'be done in accordance with San Joaquin County <br /> ordinances, state laws,and ru and re ns f San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 1"�D✓./ <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY. _ <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issue ce D to ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: "'ENVIRONMENTAL,HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201— <br />