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r _ _Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION r <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i here made to carry n business in the jurisdictional area of the San Joaquin Local H It 'str t, <br /> HBusiness Name (DBA) Address <br /> z Owner .-Address <br /> Firm Partners, Addresses and Telephone Num ers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. R +-� <br /> LApplicants Name (Print) _ F Title Date /I <br /> Please check Applicable Category (1'-7)and FIN in the Required Information 4. til] /V7�a1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i a <br /> For July 1, June 30,19 =' == "' -:.Disposal Sites ' 1 <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. IA <br /> Capacity y, 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. ❑ 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 (Al <br /> Job Address/Location - ` <br /> Owner` Address # � <br /> SEPTIC TANK ❑ CESSPOOL' LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> W 11 REPAIR ❑ OTHER <br /> PERMANENT . ❑ TEMPORARY <br /> NEW <br /> [� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction t Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 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 /> G <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatio a San Joaquin Local H Ith District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT.USE ONLY - �.�' <br /> Fee IS Due: [I ANNUALLY ❑-PER UNIT ❑ PPR SITE EI EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 37 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHFCKED <br /> BASE EXPLANATION DATE - DATE - REMITTED pry - <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS S 4 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ---------------- <br /> b <br /> 6 <br /> Received by Date I. Receipt No. Permit No. Issuance Date M iled Delivered <br /> ¢s- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., ox 2009 STOCKTON,CA 95201 <br />