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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> " (For Non-Translerable, Revocable,and Suspendable) <br /> SEPTRGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i <br /> LIQUID WASTE <br /> Applicationsyrs,h_e�rebyy made o Carryon siness in e' d' tional area of the San�quin ocal Health District <br /> HBusiness Name (DBu� Address <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses ang.,Telephone Numbers or <br /> aBusiness Telephone No. x$l�S - Emergency Telephone No. <br /> 12,2S <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date a 9'" �- <br /> i <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 /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. { <br /> Capacity Gal., Weights & Measures No. <br /> f <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 I <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 LL ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address ocation q r' <br /> Address <br /> L!7 _'TIC TANK CESSPOOLEACHI FIELD SEEPAGE PIT ❑ PACKAGE PLANT. <br /> Ld PERMANENT ❑ TEMPORARY IJ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ` <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified d <br /> -Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 1. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. Q <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 nd regulations of the San Joaquin.Local Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Received By January 31 El July l &Received By July 31 ( S <br /> REMIT 6? <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AlvOUI`kI> <br /> FEE 41 \ <br /> LESS <br /> PRORATION <br /> d'! k <br /> PLUS I <br /> PENALTY <br /> OTHER <br /> OTHER ��11 <br /> iv Date Receipt No. Permit No. I uace ate Mailed Delivered <br /> Rece ed b y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />