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Applications Will Be Processed When Submitted Properly Completed.Be SureTosign Ine %pp1]t,0LnJ11- <br /> APPLICATION <br /> (For Non-Transferable) Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica �n is hereby ade to carry on business in the jurisdictional area of the San Joaquin Local Health D' trict <br /> y 13usines Name (DBA) Address Q <br /> I- Address -� <br /> zz Owne <br /> Firm Partners, Addresses and Telephone Numbers Emer enc Telephone No.— <br /> CL Business Telephone No. g y t <br /> a <br /> Contractor Licence No. J, Date <br /> Title <br /> Applicants Name (PrintJC, <br /> j <br /> Please check Appiicablgory (1-7) an�FFll heRequired Information <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites j <br /> Description(Make/Yr.,-.Colci CAL. Liccnse Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Pair ingAddress <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. K`67 <br /> - - <br /> R.S. or R.C.E. Name - <br /> Test Location Test Date/Time <br /> . 'SANITATION <br /> - r <br /> 4. 91"SANITATION P'ERfS <br /> Job Adir/ c�I Address <br /> -, 1-4 <br /> Owner <br /> El SEPTIC TANK ❑ CESSPOOL R-_EACHING - <br /> FIELD O'SEEPAGE PIT ❑ PACKAGE PLANT <br /> {�� ❑ OTHER - <br /> Lo PERMANENT ❑ TEMPORARY <br /> 11 NEW (�'1iEP$IR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30. 19 <br /> Type Construction Disposal Site <br /> I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT Foily 1-, -June"30, 19 Where Certified <br /> Operator Name <br /> Plant Location - <br /> PNo. Units Served <br /> Plant Capacity = <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> j SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ 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, a d rules and gulations of the San Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMI BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION ' <br /> DATE REMITTED AMOUNT <br /> FEE <br /> I <br /> LESS <br /> PRORATION - ti <br /> PLUS oe <br /> PENALTY Y <br /> ti <br /> OTHER <br /> OTHER <br /> I <br /> Receipt No. Pe mit No. Issuance Date Mailed Delivered <br /> Rece' d by Date .,,, 1601 E.HAZELTON AYE.,P.O.Box 2004 STOCKTON,CA 95201 <br /> - PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES , <br />