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Applications Will be ProcesSeo Wnen -)UDmnleo riupm..' ��•••r•�•`•"• -` "-•'• •- -•_•• •- -APPLICATION <br /> on-Transferable, Revocable,and Suspend a� SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h eby made to ar on busi ess in t isdi�tional area Of the��oaqu n Local Health Distr t <br /> t� �{y� <br /> 3Msiness Name (D A) Address <br /> Dwner Address c� <br /> n Partners, Addresses and T�eleOphone Numbe <br /> E...>iness Telephone No. , Emergency Telephone No. 1 <br /> Contractor Licence No. - <br /> f Dlicants Name (Print) Title Date <br /> F ,ase check Applicable Category (1-7) and Fill in the Required nformation <br /> 1 ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> F-July 1, June 30, 19 Disposal Sites <br /> [ scription(Make/Yr., Color) <br /> CAL. License No. CAL. L7::.-,se Re-e-r.-al No. <br /> SZ'rial No. <br /> Capacity Gal., Weights & Measures No. <br /> I uipment Parking Address <br /> ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> �. of Vehicles Stored <br /> �. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> A.S. or R.C.E. Name R.S. or R.C.E. No. <br /> !stt tion <br /> LoTest Date/Time <br /> r. L SANITATION PERMIT <br /> 2 3 N 3 <br /> Job Address/L cation -7 E <br /> wrier A—f Address 6c <br /> fie), SEPTIC TANK ❑ CESSPOOL ❑ LEACHING [&"A PACKAGE PLANT 1 <br /> LJ PERMANENT ❑ TEMPORARY 1:3W NEW EPAIR ❑ OTHER CI' <br /> ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> ype Construction Disposal Site <br /> 'no. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> ,perator Name -r <br /> plant Location <br /> No. Units Served <br /> Plant Capacity <br /> . ❑ LAUNDRY For July 1, - June 30, 19 <br /> ;IZE: ❑ 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 pith San Joaquin County <br /> ordinances, state laws, and rules 0 regulations of t an 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 &Received By January 31 ❑ July 1 &Recewed By July 31 <br /> REMIT <br /> BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> O <br /> FEE \J <br /> LESS <br /> PRORATION <br /> PLUS y f <br /> PENALTY <br /> / i <br /> OTHER <br /> OTHER <br /> J <br /> Received by <br /> Date Receipt No. Permit No I uance ate Mailed Del e <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95 <br />