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Applications Will Be ProcessedWhenbuom111eorroperny..�„w��..• �� --- <br /> APPLICATION <br /> (For Non-TransferEbl,--,1Rgvocable, and Suspendable) SEPTAGE <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 v <br /> yBusiness Name (DBA) Address <br /> I Owner Address <br /> I <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. — <br /> a <br /> Contractor Licence No. Date�– <br /> Applicants Name (Print) Title <br /> ' <br /> Please check Applicable Category(1-7) and Fill in the Required Information r� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description (Make/Yr., Color) CAL. License 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 /> No. of Vehicles Stored <br /> Y: <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> RZ-- <br /> r R.CE. No. <br /> R.S. or R.C.E. Name <br /> , <br /> Test Location Test Date <br /> 4. NITATION PERMIT <br /> Job A ress/Location <br /> Owne Address <br /> ❑ TIC K " ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGr'PI r ❑ PA E PLANT <br /> ❑ MA T ❑ TEMPORARY ❑ NEW REPAIR ❑ IER <br /> 5. CHE AL TOILETS For July 1, -June 30, 19 <br /> Type Const tion Disposal Site" <br /> OL NU <br /> Equipment Storage/Clearojg ocation(s) 90 <br /> g, P AGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Oper to me � V'4"I'19+r�'Certi�ied <br /> !--I rr <br /> Plant Ln <br /> Plant Ca Ity <br /> N . Units Served <br /> 7. © DRY 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 /> 1 hereby certify that I have prepared this application and that the work v4fl be done in acc r ith San Joaq in County <br /> ordinances, stale laws, and rules and regulations of the San J Cocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 15 Due. 11 "ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju.iy 1 &ReceivedByJuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> .PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by - <br /> 1601 E.HAZELTDN AVE.,P.D.Box 2009 STOCKTON,CA 9 <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />