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APPLICATION <br /> or Non-Transferable,Revocable,and Suspend SEPTAGE l <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 /> Business Name (DBA) . l Address <br /> ±Owner [,ref Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> c��/.�,, <br /> Business Telephone No. � 'L-� Emergency Telephone No. <br /> ±Contractor Licence No. <br /> Applicants Name (Print) Title Date <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) <br /> Serial No. CAL. License No. .CAL. License Renewal No. <br /> Capacity Gel.,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 A.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner VA �6-j Ad(treS449115p,s <br /> 111-St <br /> PTIC TANK 91-CESSPOOL ❑ LEACHING FIELD � SEEPAGE PIT ❑ PACKAGE PLANT <br /> ,., ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER i �F <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 (/ <br /> Type Construction Disposal Site- <br /> No. of Units Equipment Storage/Cleaning Location(Sj <br /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19- U <br /> OperatorName 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 re ulatio sof the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX 'y — O�' ✓ <br /> 6 <br /> ` FOR DEPARTMENT USE,ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE. _1] EACH ❑ January.1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> - _ _DATE,_ _ DATE REMITTED AMOUNT <br /> FEE 6 <br /> LESS <br /> PR'RATIQN <br /> 6. PLUS <br /> PENALTY,,- <br /> 01 <br /> ` OTHER ._ .._ ._. ._..... . .__ <br /> a -3 <br /> Received by Date Receipt No Permit No. hetuancir Date Mailed Delivered <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE,P.O.Boa NO STOCKTON,CA 95201 <br />