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• Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> M. APPLICATION A <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the SanJoaquin Local Health District <br /> r <br /> .Business Name (DBA) G Address <br /> aOwner_ G Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a -` Emergency Telephone No. <br /> a Business Telephone No. l <br /> Contractor Licence No. <br /> Applicants Name (Print) o Title bate <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O� <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 Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 } <br /> No. of Vehicles Stored <br /> Y <br /> No.'of Chemical Toilets Stored R ' <br /> i F <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 <br /> Job Address/LocationXn�_ ' <br /> Owner "4 ^- w Address `` -- <br /> `'❑ SEPTIC—TANK 11CESSPOOL � LEACHING FIELD 13SE AGE PIT_ ❑ PACKAGEPf<RNT <br /> EPAiR rt, ❑ OTHER ' ?rP_ q _- . <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW `� -; �Z <br /> T 5:" ❑ CHEMICAL TOILETS For'July 1,=June 30, 19: <br /> t Type Construction Disposal Site <br /> I' No.of Units Equipment Storage/Cleaning Locations) <br /> t <br /> 6-11 PACKAGE TREATMENT'PLANT For July,i, -June 30, 19 i r <br /> Operator Name 1 Where Certified <br /> q Plant Location <br /> Plant Capacity No. Units Served = <br /> 7. ElLAUNDRY 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 /> � l � <br /> b <br /> P I hereby certify that I have.prepared this application and that the work,will be done in accordance with San Joaquin y i <br /> i ordinances, state laws, and rules and re lations of the San Joaquin Local Health District.` <br /> I _ <br /> APPLICANT'S SIGNATURE X R i <br /> r <br /> t <br /> t FOR DEPARTMENT USE ONLY <br /> -Fee.Is-Due: ❑ ANNUALLY ❑ PER UNIT a>IER SITE ❑ EACH ❑ January'i &Received By January 31 ❑ July 1 R Received By July,31 <br /> REMIT <br /> ' BILLING a REMITTANCE $ AMOUNT DUE CHECKED ' <br /> BASE EXPLANATION; AMOUNT ' <br /> DATE DATE REMITTED / - <br /> t FEE <br /> Y LESS D� <br /> PRORATION <br /> t t ' <br /> PL-US - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 03 (o <br /> k'r <br /> Received by `z Date Receipt No. ,- 'Permit No. '- I uanc Dat Mailed � Delivered ,- <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ;.� <br />