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JApplications Will Se Processed When Submitted Properly Completed. lye bure Io alyil �—^rr••� <br /> APPLICATION r <br /> j (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> .. " ENVIRONMENTAL HEALTH PERMIT <br /> ,. -F: LIQUID WASTE r%' <br /> Application is ereb made to carryon business in the jurisdictional area of the San Joaquin Local H h Distri o �e <br /> 12 <br /> Business Name (DBA) <br /> t� Add ss <br /> Address <br /> aOwner <br /> Firm Partners, Addresses and Telephone NumbersC7 r Emergency Telephone No. <br /> CL Business Telephone No. <br /> Contractor Licence No. Date F 9 <br /> o �. Title <br /> L 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 /> Description(Make/Yr., Color) " <br /> CAL. Lic-7se Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> Z. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3• ❑ PERCOLATION TEST R.S. or R.G.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. YSANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> i 13 REPAIR OTHER <br /> PERMANENT ❑ TEMPORARY C NEW <br /> ❑ <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 /> I Plant Capacity <br /> 7. 0 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 /> 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 an regula'ons of he S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> r ° January b&Received By January 31 ❑ .Bury 1 &Received By July 31 <br /> l Fee Is Due: ANNUALLY Q PER UNIT ❑ PER SITE ❑ EACH y REM17 <br /> BILLING, REMITTANCE $ AMOUNT DUE CHECKED <br /> . BASTE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 1 FEE <br /> LESS S r~ <br /> f PRORATION <br /> r PLUS <br /> PENALTY <br /> f OTHER <br /> { F <br /> I OTHER t� <br /> I <br /> Delivered <br /> Receipt No- Permit No. Issuance Date ' Mailed <br /> Received by ate 1601 E.HAZELTON AVE.,P.O.Boz 2009 .STOCKTON,OA 95261 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> r. <br />