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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTneAppncauon. <br /> APPLICATION <br /> ` n (For Non-Transferable,Revocable, and Suspendable) SEPTAGE y, <br /> 1� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> _ Application�wJierel2Y meto carr�n b cine s in the}ur�sdictional area of the San Joaquin L al Health District <br /> rn Business Name (DBA) lr �-t �S Y I;6e �- Address �sG UT Q f 1 <br /> z Owner Address = <br /> a - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Emergency Telephone No. <br /> a. Business Telephone No, eI <br /> Contractor licence No. 1 ?�� <br /> Title Date <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. L icc a Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking.Address <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored I <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,3�O E f 2 0 <br /> Job Address/Location <br /> Owner Address <br /> k 1­1SEPTIC TANK 1:1CESSPOOL 13LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 /6o6 o6 6n l- p�� _ 410' 1/Illef <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Where Certified <br /> Operator Name <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 /> r <br /> ! I hereby certify that I have prepared this application and that the rk will be done in accordance with San Joaquin County <br /> ordinances, state laws, art "nd regulations of thelS§n Joaqui ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> S Fee I5 Due: Cl ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 _ <br /> - BASE- EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1 FEE <br /> r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER `a– <br /> Received by Date Receipt No- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />