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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign 1neAppllcailvn. <br /> ' APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE , Q <br /> Application is hereby made to carry on business in the jurisdictional area of the Joaqui Local Health District a r <br /> I <br /> .=. . �rAddress s J <br /> F Business Name (DBA) R <br /> Address <br /> z Owner <br /> d <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> a Business Telephone No. <br /> � ��� }' Emergency Telephone No. <br /> Contractor Licence No. Gc�f <br /> Applicants Name (Print) <br /> Title Date <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 /> Equipment Parking Address <br /> 2. la PUMPER YARD E <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 Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location c 11� l' <br /> Owper A ` Address = <br /> Er SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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 /> Where Certified <br /> Operator Name <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., 11 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 r ulati s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> 0 <br /> OF FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 ceived By January 31 ❑ July 1 &Receiv AEMITBy uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE{4 REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> OTHER } <br /> —7 <br /> g Z�o 7 <br /> Received by Date Re ipt No. Permit No. Issu nce Oate ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA? <br />