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Applications Will Be Processed When Submitted Properly Completed. de sure Ioalgn 111w•+rr"•�� - <br /> APPLICATION <br /> (For Non-Transferable, Revocable,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 <br /> •p Address <br /> r Business Name (DBA) �- - 4• � �r{. ''- <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers C <br /> a Business Telephone No. Emergency Telephone No. r <br />' 4 <br /> Contractor Licence No. <br /> JL Title Date <br /> LApplicants Name (Print) _11 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <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 /> Gal.,Weights & Measures No: - <br /> Capacity _ - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD E _ <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 <br /> Test Location Test Date/Time <br /> l <br /> 4. ❑ SANITATION PERMITAC <br /> Job Address/Location <br /> O Address <br /> if SEPTIC TANK El CESSPOOL 51�ACHING FIELD ❑ S_EEPAGE PIT ❑; PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR El OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 F. <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Na. UnitsServed <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 /> 1 'hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, 4,nd rules and re Iatio of San-Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Y. <br /> Fee IS Due: ❑ ANNUALLY ❑ <br /> PER UNIT ❑ PE R SITE ❑ EACH ❑ January Received By January 31 ❑ July 1 &Received BAluly 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION l <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. - Permit No, I sua ce Date Mailed Delivered <br /> Received by - t601 E.HAZELTON AVE.,P.O.Boa 20D9 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />