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Applications Will Be Processed When Submitted Properly Completed, Be SuTo 5i9gtThe <br /> PPllcaZ <br /> APPLICATION ��EE'' F !r� <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,. LIQUID WASTE <br /> Application i hereby de to carry on sin sin the jurisdictional area of the San Joaquin Local He <br /> Business Name (DBA) Address <br /> r Address <br /> z Owner <br /> a <br /> Firm Partners, A dre ses o e umbers <br /> Emergency Telephone No. <br /> a. Business Telephone No. <br /> Contractor Licence No. Date <br /> L Applicants Name (Print) <br /> Title t <br /> Please check Applicable Category (1-7) and Fill in the Required information <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 iDisposal Sites <br /> Description(Make/Yr., Color) CAL, License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored F <br /> 3. ❑ PERCOLATION TEST <br /> " R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test D to/Time <br /> Test Location ; <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> caner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT lS` <br /> 111���r� 13 REPAIR 13 OTHER <br /> 19PERMANENT El TEMPORARY NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -iuft 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> iK.1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name + i <br /> Plant Location - <br /> No:Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,- June 30, 19 } <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify that 1 have prepared this application a the work will be-done in accordance with San Joaquin County <br /> ordinances, state laws, an rul s g do s of th Sa Jo quin-Local Health D' trict. <br /> j APPLICANT'S SIGNATURE X <br /> ` FOR DEPARTMENT USE ONLY <br /> F Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Suiy 1 &Recew d By REMITu y 31 <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> DATE DATE REMITTED AMOUNT <br /> i CZ <br /> F FEE ++ LA <br /> LESS <br /> PRORATION <br /> PLUS , r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - Receipt <br /> Recei t No. Permit No. ssuanc Date MaHed Delivered <br /> Received by 'Date P <br /> _ 1601'E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICE5 .g.r <br /> j <br />