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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication.i <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's here m t rry on b, nes 'n t �urisdictignal area of the Joaq Local He th D 'ct <br /> Business7(DBA) Address <br /> Owner Address1/—,/- <br /> z � <br /> Firm Partners, Addresses an T le hone Numbers �� `� <br /> a.Business Telephone No. r 7 �P 3 Emergency Telephone No. <br /> Contractor Licence No. 6 r <br /> Applicants Name(Print) Title .f�.0 Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information L�I <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 Renewai 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 n <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. [a-BANITATION PERMIT <br /> Job Address/ ation Z- <br /> Owner Address <br /> WSEPTIC TANK ElCESSPOOL ErLEACHING FIELD CPAGE PIT 13 PACKAGE PLANT <br /> �'ERMANENT ❑ TEMPORARY U-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 i, -June 30, 19 r �I <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served Q <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. L <br /> ❑'DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this applLgation and that the work will be done in accordance with San Joaquin County # <br /> P ordinances, state laws, and r es a d regulat' s th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> `! FOR DEPARTMENT USE ONLY <br /> i' Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE EI EACH El January 1 &Received By January 31 July 1 &Received By July 31 7 <br /> REMI \ �{ <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECK <br /> DATE DATE REMITTED (� A IJ <br /> 4 <br /> ;FEEl"S <br /> PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No Permit No. I .uance ate Mailed Delivered <br /> AppL1GANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON WE.,P.O.Boil 2009 STOCKTON,CA 95201 <br /> fid _ '..; <br />