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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,I <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio h eby ma o car; on busi ss in th€jurisdictional area of the San Joaquin Lo 1 He h tr'44, <br /> yBusiness N e DBA) Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Tele h e^Uumbers <br /> aBusiness Telephone No. ; Emergency Telephone No. <br /> Contractor Licence No. f <br /> L Applicants 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) �C} <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 <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 Location Test Date/Time f <br /> 4. OSANITATION PERMIT 44 <br /> Job Address/ C tion Q <br /> Owner Address W' <br /> SEPTIC TANK ❑ CESSPOOL � LEACHING FIELD SEEPAGE PIT.2- PACKAGE PLANT <br /> ' rPERMANENT 11 TEMPORARY IFr NEW ❑ REPAIR ❑ 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) <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 repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ru s asld regulations a San J quin 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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ; <br /> FEE <br /> .LESS {�7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> f h <br /> 3l0 7 iry <br /> Received by Date Receipt No. - Permit No. lssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - - 1'601.E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON,CA 95201 <br /> s .f <br />