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Applications Will Be Processed When 5ubAmPPLICATION <br /> ofr <br /> � <br /> t , (For Non-Transferable,Revocable,and Suspend able) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> a <br /> �G�� LIQUID WASTE <br /> Application is hereby made to carry on business In the jurisdictional areaoftheSan Joaquin Local Health District <br /> rn Business Name (DBA) Address Address <br /> aOwner a <br /> 9 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL <br /> Business Telephone No. 5-- <br /> a Contractor Licence No. Title Date <br /> Applicants Name (Print) <br /> in the Required Information <br /> Please check Applicable Category (1-7)and Fill <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal <br /> Sites <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. Lic'nse Renewal No. <br /> Serial No. <br /> Gal.,Weights & Measures No. <br /> Capacity , <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 R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time m f fg Wei B 1 9� <br /> Test Location l — <br /> 4. ❑ SANITATION PERMI O �G e n C <br /> Job Address/Location I <br /> Ad ress <br /> O_w�er �"LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT �C? <br /> W/SEPTIC TANK CESSPOOL ❑ REPAIR 13 OTHER FA\ <br /> ❑ PERMANENT ❑ TEMPORARY C1 NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1pisposal Site <br /> Type Construction <br /> No, of Units Equipment Storage/Cleaning Location(s) C <br /> g, ❑ 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 30,19More Than 1,000 Sq. Ft. <br /> SIZE: C1 Less Than 1,000 Sq. Ft., <br /> El❑ 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 aquin Health District. <br /> Lo <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ January 1 &R ived 6y January 3i ❑ July 1 &Received By Juky 31 <br /> Fee Is Due: ❑ ANNUALLY C1 PER UNIT PER SITE ❑ EACH IT <br /> BILLING REMITTANC $ AMOUN7 DUE CHECKED �i <br /> BASE EXPLANATION DATE T REMVT7ED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t [ <br /> OTHER I <br /> OTHER <br /> . <br /> Issuance Date Mailed DON ed <br /> eceipt NoPermit No. � <br /> RDate 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br /> eceived by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br />