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W Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> " • �M ENVIRONMENTA _."EA4LTH PERMIT <br /> LIQUID WASTE . <br /> Application is hereb made to c. r on busi ess'n the urisdictional area of the.San Jo uin Lo ca,,Healjh istrict <br /> yBusiness Name (DBA) y Address <br /> I z Owner .— F " _,r` Address ' <br /> a r a <br /> Firm Partners, Addresses and.Telephone Numbers <br /> J <br /> CL Business Telephone No. I/ Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print} - <br /> _ _ Title Date <br /> I <br /> Please chedk Applicable Category(1-7) and Fill in the Required Information <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 " Disposal Sites <br /> t Description(Make/Yr., Color) — <br /> Serial No. I CAL, License No, CAL. License Renewal No. <br /> k <br /> Capacity Gal., Weights & Measures No. - <br /> Equipment Parking Address 'I - <br /> 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 <br /> r No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST <br /> __R:Sror-R:C.E Name R.S. or R.C.E. No. <br /> ' Test Location Test Date/Time <br /> 4. ❑ SANITATION PER ��• <br /> Job AddLe s/9Location ,. <br /> Owner $ Address r. t. < VU <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT .❑ PACKAGE PLANT <br /> ❑ PERM ANENT ❑ TEMPORARY ❑ NEW REPAfR 1i OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> i Type Construction !' Disposal Site <br /> n <br /> E ui met Stora 'a/Cleanin Location s <br /> No. of Units _ .. 4 P 9 9 0.�. - <br /> i 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 /> „ r <br /> ilk <br /> �x l hereby certify t �'I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law's, and rules a reg ations f the an oaquin Local Health District. <br /> k <br /> APPLICANT'S SIGNATURE - <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> r. Fee Is Due: ❑ ANNUALLY.iii, El PER UNIT ❑ PER SITE 11 EACH ❑January 1 k Received By January 31 ❑ July 1 &Received By July 31 <br /> !, REMIT <br /> 'I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ' BASE EXPLANATION DATE DATE REMITTED ' <br /> li AMOUNT <br /> FEE lot <br /> -1 S <br /> LESS ;I ; <br /> PRORATION ! _ - <br /> PLUS <br /> PENALTY _ ^} <br /> i <br /> i OTHER '! <br /> OTHER <br /> 17 <br /> Is Date Mailed D red <br /> Received by Date Receipt No. Permit No. seance elive <br /> } + APPLlCANT—RETURN ALL COPI 5 TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br />