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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. L <br /> �{ APPLICATION <br /> k (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application I =?to c ryon business in the jurisdictional area of t an aquin Local Healt Di rict <br /> rn Business Name (DBA) , Address • <br /> aOwner Address <br /> J Firm Partners, Addresses and Telep n umbers <br /> a. Business Telephone No. I Emergency Telephone No. - <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date R-� <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 Gal., Weights& Measures No. <br /> Equipment Parkin Address f' <br /> 2. ❑"PUMPER YARD p <br /> For July 1, June 30, 19 x <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R4S:or R.C.E. Name` R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4.t SANITATION PERMI { 1 <br /> Job Address/ cati <br /> owner,.' i Address = <br /> Pr,S TANK ElCESSPOOL - 19LEACHING FIELD )9SEEPAGE PIT ❑ PACKAGE,PLANT <br /> PERMANENT 11❑ TEMPORPRY NEW. ❑ REPAIR , ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS 'For July f1, 'June 30, 19 s10 <br /> - g' <br /> Type Construction -,' .bispbsal'Site r <br /> No. of Units- a:- t Equipment Storage/Cleaning Location(s) i <br /> 6 ❑ PACKAGE,TREATMENT PLrANT For July 1., �June 30, 19 <br /> �.. r' # <br /> Operator Name `.. � Where Certified <br /> Plant Location <br /> a <br /> Plant Capacity _ l No. Units Served r <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 /> b <br /> 11L hereby certify that l Piave prepared this application and that the work will be done in accordance with San Joaquin County <br /> t ordinances, state laws, and rules and reyulation&of the San Joaquin Local Health District. t <br /> APPLICAO'S SIGNATURE X <br /> FOR.DEPARTMENT USE ONLY <br /> ' <br /> r -- Fee Is'Due:.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH H- 1 ❑ January 1 &Recei By January 31 _. ❑ July 1 &Received By July 31 t' <br /> -tom y.... - - - <br /> Y>« i REMIT { <br /> 1 BASE EXPLANATION BILLING LREMITTANCE $ AMOUNT DUE CHECKED <br /> p, DATE' DATE REMITTED <br /> AMOUNT <br /> FEE SOS CJ� U � <br /> LESS J qv- <br /> PRORATION <br /> PLUS <br /> PENALTY -- <br /> ` r <br /> OTHER <br /> OTHER t <br /> I <br /> Received by Date } Receipt No. Permit No. Ksuanc4f Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 85201 <br />