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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 Suspendabte) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> a. LIQUID WASTE <br /> Applicati n l h eb to carry' n bust s in the'url di tonal area of the 5a aquin Local Health District \� <br /> ,n Busin(�ss Nam (ORAS Address+ v <br /> z Owner Address -�- <br /> a <br /> 1 2 Firm Partners, Addresses and Tele e,Uumbers <br /> aBusiness Telephone No. Emergency Telephone No. 0 <br /> Contractor Licence No. °` � n <br /> LApplicantsf•Name (Print) 4—, Title /j . Date <br /> Please check Applicable.Category (1-7)and Fill in the Required Information <br /> 1. QiFUMP.ER VEHICLE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 36 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 (P <br /> 2. 17 PUMPER YARD G <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 /> t Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT a a <br /> Job Add r s/Location ��✓� ® ' / <br /> Owner Address , <br /> 4 <br /> ❑ SEPTIC TANK ❑ CESS OOL EACHING FIELD X7SEEPAGE PIT ❑ PACKAGE PLANT <br /> KPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction.� +,t t._ _ �'` Disposal Site <br /> No. of Unitst, ^_w .-�..--- - --�- }-Equipment Storage/Cleaning Location(s) <br /> {`6. `❑ PACKAGE'TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name x "` Where Certified <br /> is Plant Location <br /> Plant Capacity -' <br /> ')"T 1—_. N_o. Units Served <br /> �- 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑rLessThanl=1000Sq=F.t =❑..More Than 1,000 Sq. Ft. i <br /> ❑4` DRY CLEANING, Chemicals Used/Amount/Mo. I - <br /> f <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, at and regulation7 of the Sa oaquin Local Health Is riot. <br /> F APPLICANT'S SIGNATURE X i <br /> FOR DEPARTMENT USE ONLY <br /> 'Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LA PER SITE ClEACH © 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 /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION A <br /> r r <br /> PLUS , ! <br /> PENALTY (. <br /> OTHER a <br /> OTHER r. <br /> - '5`f ? �- <br /> Received by Date f Receipt No. Permit No fissuan a Date Mailed De iv d . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.'HAZELTON AVE.,P.O.Box 2009 STOCKTON, A 95201 <br />