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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign inerapPIMULI II. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 1.34 <br /> l LIQUID WASTE <br /> Applicatio Is a by ma o car n�,iusiness in the jurisdictional area of the San Joaquin Local Health Di tri t <br /> L Address ;_ <br /> FBusines <br /> Owners Nam (DBA <br /> 4 - <br /> Address <br /> J Firm Partners, Addresses and Telephone !m�els Emergency Telephone.No.- <br /> IL Business Telephone No. / (p _ y <br /> Contractor Licence No. s j _.Date <br /> Title <br /> Applicants Name (Print) ^ -� <br /> Please check Applicable Category (1-7)-and Fill in the Required Information C, <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. x�; CAL. License No. <br /> *.F ' Gal., Weights &Measures No. <br /> k Capacity � .; <br /> Equipment Parking Address ; .f <br /> *; <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> 5 <br /> No.of Vehicles Stored a <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ` <br /> ;r <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location ` f Test Date/Time <br /> 4. ANITATIONPERMIT <br /> Job Address/L cation <br /> Owner - -' Address <br /> SEPTIC TANK CESSPOOL 'LEACHING FIELD #.D SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 <br /> V PERMANENT ❑ TEMPORARY 0NEW ❑ REPAIR aW OTHER a X 1 d � <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Jun&30, 19 <br /> Type Construction y l Disposal Site <br /> No. of Units Equipment,Storage/CleanIng Location(s) p ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,'-June 30, 19 Where Certified <br /> rn <br /> Operator Name <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 /> w <br /> I hereby certify that I hav ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d ruts a re Io s of a San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY �I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑!EACH ;❑ January 1 &Received By January 31 ❑ July 1 &ReceiveHtlFBdylTuiy 31 <br /> BASE EXPLANATION + -BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> - � Saa <br /> FEElei <br /> 1 <br /> LESS + <br /> PRORATION <br /> PLUS <br /> PENALTY y i <br /> OTHER 4 <br /> OTHER.. <br /> Received by <br /> Date Receipt No. Permit No. Issua ce to Mailed Delivered <br /> - APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES <br /> 1601 E.HAZEL- ,'P.O.Box 2099 STOCKTON,CA 95201 - <br />