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Applications Will Be Processed When SubmiittteeL'CAT`ONp1eted. a ure o ,. <br /> (For Non-Transferable, Revocable, and 5uspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio ,is In by ade to car o� iness in the urisdictional area of the 5.-an�Jo uin Local �Ith Dis ict <br /> ` Address <br /> mBusiness Name (DBA) Address <br /> aOwner <br /> J Firm Partners, Addresses and Telephone 11 <br /> Emergency Telephone No. <br /> CLI <br /> Business Telephone No. <br /> . 51 <br /> Contractor Licence No. Date �Q <br /> Title CA <br /> Applicants Name (Print) <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 <br /> Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL License No. <br /> Gal,, Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2, ❑ PUMPER YARD <br /> f For July 1, June 30, 19 <br /> tt No. of Vehicles Stored <br /> F No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> .. Test Date/Time .� <br /> _ Test Location ' <br /> ,f <br /> q, SANITATION PERMIT 2- V <br /> Job Addlie ation Address <br /> O ner ❑ PACKA PLANT ; <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ REPAISEEPR <br /> E PIT ❑ OTHER Z bAr-5 ¢zeA Sid-#- of <br /> PERMANENT ❑ TEMPORARY �NEW - <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction _ <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name - <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> a 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 prepared this application and that the work will be done in ac o�iance with San Joaquin County <br /> ordinances, state laws, a rules and re ulatio�thequin Local Health Dist ict' <br /> APPLICANT'S SIGNATURE X / <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ nuary.1 &Received By January 31 ❑ July 1 &ReceiveR By July 31 <br /> 5 BILLING R IT CE $ AMOUNT DUE CHECKED <br /> i BASE EXPLANATION p EMITTED AMOUNT <br /> DATE <br /> FEE <br /> I LESS <br /> .PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 01111 <br /> Receipt No. Permit No. Issuance ate Mailed Delivered <br /> Received'by Date - <br /> 1601-E.HAZELTON AYE.,P.O:Box 2009 STOCKTON,CA 95201 <br /> APPLICANT <br /> -RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />