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~ 'Applications Will Be Processed When Submitted Properly Completed. BeSureTosign tneMppneah-1. <br /> FF r APPLICATION <br /> (For Non-Transferabtp RGV'bmble, and Suspendable) SEPTAGE 1' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i ereby made o car on ness' th juris 1 tional area of the a ui ��Health District <br /> . Address <br /> Business Nam (DBA) <br /> C. Address <br /> < Owner <br /> O Firm Partners, Addresses and Telephone Num ers Emer envy Telephone No. <br /> d Business Telephone No. 3 O g <br /> d <br /> ( Contractor Licence No. �Q.�. " Date_ �Uy� <br /> Title <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 Disposal Sites <br /> I 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 <br /> For July 1, <br /> June 30, 19 t <br /> No. of Vehicles Stored <br /> 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 Dation Test Date/Time <br /> q. LE SANITATION PERMIT <br /> Job Address/Locaf n = S-Q <br /> Owners Address <br /> .i ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEPAI GE PIT ❑ OTHER --� <br /> . ❑ PERMANENT ❑ TEMPORARY ❑ NEW EPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> rn <br /> No. of Units Equipment Storage/Cleaning Location(s) C <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified <br /> Operator Name l <br /> Plant Location <br /> No. Units Served- <br /> Plant Capacity <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 /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C unty <br /> ordinances, state laws, and rules an egulations of th a loaquin Local Health District. s n <br /> 3 "gr !� <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> _ PER SITE ❑ EACH ❑ January 1 &Received By-Janu ry 31 ❑ 3uty 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE r �e ® " <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER -- , <br /> OTHER <br /> Date Receipt No. Permit No. Issuan a Dat Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES � - 1601 E.HAZELTON AVE.,AYEP.O.Box 2009 STOCKTON,CA 1152D <br />