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APPLICATION <br /> x Non-Transferable,Revocable,and Suspendal SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i here Y made to carry, n business in the jurisdictional area of the San Joaquin Local H Ith•®F]estr t <br /> „Business Name (DBA) Address. ��� 4(� � �z <br /> I-Owner Address Y <br /> i <br /> Firm Partners, Address s and Telephone Num ers <br /> $ Business Telephone No. -Emergency Telephone No. <br /> I Contractor Licence No. <br /> 4 Applicants Name (Print) Title Date /I <br /> Please check Applicable Category (1-7)and Fill in the Required Information /VXVI <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - � ) <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. Ifl <br /> Capacity Gal., Weights & Measures No. <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 <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT CA3 <br /> Job Address/f'_ocation <br /> O ner - — Address ❑ PACKAGE PLANT <br /> SEPTIC TANK 13 CESSPOOL' EACHING FIELD GSEEPAGE PIT <br /> PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-Jun9 30, 19 <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 - - - -- -'- <br /> Operator Name Where Certified <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 /> 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 regulatio a San Joaquin Local H9#lth District. <br /> APPLICANT'S SIGNATURE X sG'�"')" 4 - <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEELESS <br /> 4 yy <br /> PRORATION .� J <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> OTHER b <br /> "I <br /> Received by Date Receipt No. Permit No. Issuance Date M fled Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., 0c 2009 STOCKTON,CA 85201 <br />