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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 Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> LIQUID WASTE <br /> App ica is hereby made to Carry on business in the jurisdictional area of the San ay� n cal Health District <br /> Business-Name (DB ) P� J" l __ _ ___ _ Address4.. " ,._— �y/ <br /> a Owner [l 4"34"3 zhvcn Address <br /> Firm Partners, Addresses and Telephone NJ�rlbers <br /> M Business Telephone No. -,7�" .1, Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) d Title Dater <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 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3.-13-PERCOLATION TEST- <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time _ <br /> 4. '-SANITATION PERMIT }j � J <br /> Job Address/L catio <br /> Az�Owner Address <br /> JO SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT '❑ PACKAGE PLANT I <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1 i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 [ n <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) - - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> I <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 /> f . <br /> hereby certify that I hve pfrepared thi application an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws� d vlenA,.ulations of the' Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X fir { <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> - AMOUNT '7 <br /> FEE L6 .73 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> h <br /> OTHER} <br /> lag <br /> Received by I Date Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEiTOy AY(E.,p ox 2009 STO CKTON,CA 95201 <br />