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-�- Applications Will Be Processed When Submitted Properly Completes• taeacre �+J J•y�• <br /> APPLICATION <br /> I Z (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE Health District <br /> Applicatio ereOy�made c on b ess in he'uris I nal area osthe 5 a uin oval <br /> to Business Name (D 3 ddress -� <br /> aOwner r <br /> 1 Firm Partners, Addresses and Tele hone Numbers Emergency Telephone No. (� € <br /> aBusiness Telephone <br /> Contractor Licence No., Title Date <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Int rmation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOREACH <br /> VEHICLE) <br /> For July 1, June 30, 19 Disposal <br /> es <br /> Description(Make/Yr.,Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br />'i 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 R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> f <br /> Test L ation <br /> t 4, SANITATION PERMIT <br /> ' Job Address/Location oo�` Address91.2 <br /> 0 er 48S LEACHING FIELD T ❑ PACKAGE PL <br /> Ly! SEPTIC K ❑ CESSPOOL '� ❑ REPAIR C3 OTHER �J <br /> ❑ PERMANENT 11 TEMPORARY <br /> 11dNEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> Equipment Storage/Cleaning Locations) <br /> No. of Units <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1,= June 30, 19" Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <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 /> I Q� <br /> b certify that I have prepared this application and that the work will be done in accordance with San�doaquin County <br /> I here y YV <br /> ordinances, state laws, and rul d regulations of the San Joaquin Local Health District. � <br /> APPLICANT'S SIGNATURE X <br /> i 4 <br /> FOR DEPARTMENT USE ONLY <br /> 31 <br /> Fee IS Due. ❑'ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ ar <br /> EACH .❑ January 1 &Rece January 31 ❑ July REMIT 1 &Received By July <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE R ITTED AMOUNT <br /> L/ sda <br /> FEE l <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> OTHER , <br /> OTHER ` w 3 11 L <br /> Receipt No. Permit No. <br /> Issua a Date Mailed Delivered <br /> Received by Date 1601 E.HAZELTON.AYE.,P.O.Box 2009' STOCKTON,CA 95261 <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES — <br />