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roperty <br /> re 10Wil IINV Iiiiii <br /> Applications Will Be Processed When SubAPPLiCAT1ONpleteBe u <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application he3e made to carry on b iness in the jurisdictional area of the S a L �Healt C istrict <br /> f � Add ess r <br /> Busines a (DBA) v Address r <br /> a 1-''Owner 7(1AJ/ <br /> 0 Firm Partners, Addresses and Telephone N3umbers Emergency Telephone No. a1 <br /> aBusiness Telephone No. U <br /> �Contractor Licence No. 0 w4ii Date <br /> Title ) <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUM'PER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. i <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No, i <br /> Equipment Parking Address <br /> E 2. ❑ PUMPER YARD <br /> For,July 1, June 30, 19 <br /> No. of Vehicles Stored j <br /> i <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 <br /> Test Location -� <br /> 4, Q3,4ANITATION PERMIT , <br /> Job Address/Location Address <br /> OwnerPACKAGE PLANT f <br /> El SEPTIC TANK 1:1 CESSPOOL ' Ei LEACHING FIELD ��EEPAGE PIT ❑❑ OTHER <br /> 11 PERMANENT 13 TEMPORARY <br /> ❑ NEW C�'REPAIR <br /> WL <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> � Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. 13LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> y <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this a plication and <br /> that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and gu t' ns the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received July 31 <br /> EMI <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMO NT <br /> FEE <br /> ! ,/1 <br /> LESS <br /> PRORATION <br /> ' PLUS <br /> PENALTY <br /> OTHER — <br /> OTHER <br /> Receipt No. Per o l uanc t Mailed Delivered <br /> Received by Date — qx Z l i <br /> 1601 E.HAZELTON AVE.,P.O.B 009 STOCKTON,CA 95 0 <br /> I APPLICANT—FIETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES , <br />