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Applications Will Be Processed When Submitted Properly Completed.BeSureTo sign IneAppucatrvrl. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby(made to ar busi s in the'uri tianal area of the Sa oaquin ocalHealth r,District . <br /> rn Business Nam 6A). Address— d y T--� <br /> z Owner Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> OL Business Telephone No. Emergency Telephone No. <br /> a �. <br /> i Contractor Licence No. <br /> L Applicants Name (Print) <br /> Title � Date <br /> Please check Applicable Category (1-7)and Fill in the Required formation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. I <br /> Equipment Parking Address 5 <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST <br /> 1 R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> e Test Date/Time <br /> Test L tion <br /> 4. SANITATION PERMIT <br /> Job Address/Location �, W <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEA HING FIELD - E PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWiEPAiR ❑ OTHER w <br /> 1 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> fi. 1:1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> I Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> s <br /> L <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> LL ordinances, state laws, and rules an gulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuly 1 &ReceiveR Myl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER .,/, <br /> OTHER <br /> Received by Date Receipt No. ermit No, Iss ante Date Mailed ell Bred <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMkITISERVICEs 1601 E.HAZELTON AVE.,P.O.Box 2009- -STOCKTON,CA 95201 <br />