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APPLICATIUN <br /> (For Non-Translerable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> I <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Lo <br /> cai Health District <br /> y Business Name (DBA) Address <br /> a <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No_ <br /> -J Contractor Licence No. <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) f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAS_. License No. <br /> Capacity ` Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owners Address _ <br /> ❑ SEPTIC TANK ' ❑ CESSPOOL ❑ LEACHING FIELD"` ❑ SEEPAGE-PIT !❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER A T <br /> 5. ❑ CHEMICAL TOILETSof r July 1,-June 30, 19 � <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 18 <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 and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> d By <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 ReceiveREMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE 'DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> y Received by Date Receipt No. Permit No- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br />