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s Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign ineApPllcau0n. <br /> F APPLICATION <br /> t (For Non-Transierable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> l <br /> LIQUID WASTE <br /> Applicat' s hereby made to ca on business in the risdictional area of the San Joaquin local Health DistricliY <br /> C ►JGS on d� l � Address 4�b 6-T-7e�,u 1�'## <br /> F Business '(DBA) <br /> zOwner f lei e �6�/'� Address <br /> C <br /> L Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. 19'r I <br /> LApplicants Name (Print) Title Date U <br /> Please check Applicable Category (1-7) and Fill in the Required Information C <br /> C <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites s <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. Li;,�,ee Renewal No. <br /> Serial 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 4 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERM T <br /> Job Address/Location <br /> Owner ,R� Address ❑ PACKAGE PLANT . <br /> SEPTIC TANK ❑ CESSPOOL ® L ACHING FIELD 1:1 SEEPAGE PIT ❑ OTHER S <br /> ❑ PERMANENT 1:1TEMPORARY NEW ❑REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �fi� fk s �� /��v�� <br /> Type Construction Disposal Site <br /> I. No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 E <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this application andthat the rk will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regulations of the San Joaq 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 ❑ Juiy 1 &Receiv d By REMIT 31' <br /> BASE - EXPLANATION BILLING RE AN CE $ AMOUNT DUE CHECKED <br /> DATE - ATE REMITTED AMOUNT <br /> FEE 's LESS <br /> S z <br /> PRORATION v <br /> PLUS U <br /> PENALTY prt <br /> IOTHER <br /> k <br /> OTHER <br /> IIssuance ate Mille Deliv red M <br /> Received by ate Receipt Permit No- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 95201 <br />