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�. <br /> .Applications Will Be Processed When Submitted Properly Completed. Be SureToSign <br /> APPLICATION ` <br /> - (For Non-Transterable, Revocable, and Suspendable) SEPTAGE I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District c�S <br /> S•ppAddress <br /> F Business Name (DBA) 43 <br /> I- Address <br /> a Owner <br /> Firm Partners, Addresses and ho�Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Date 3 � K—g� 1 <br /> Title r <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) CAL. Lic:ase Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> C No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.G.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 2 <br /> W00,90, /�r^7'�S Address S�rh B <br /> k Owner <br /> ❑ SEPTIC TANK E] CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT 13 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR <br /> 13 OTHER 'y "�'l.7" .Y/✓ry 5u�1v � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site O <br /> No. of Units <br /> Equipment Storage/Cleaning Location(s) OI <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified <br /> Operator Name <br /> +I Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> r 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> k 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 rule nd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE=X <br /> FOR DEPARTMENT USE ONLY <br /> j Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv d By REMIT <br /> uly 31 - <br /> II BILLING RFMITTANCE $ AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _y <br /> OTHER <br /> r - <br /> ? OTHER <br /> a 13� I3� s � <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by 1601 E.HAZELTON AVE.,P.O.9ox 2009 STOCKTON,CA 95201 <br /> - APPLICANT' RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERYICES <br />