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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAppncauon <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIII WASTE <br /> Application + reek y madet arty ¢+siness the urisdictional area of the San Joaquin Local District <br /> 1 �d �` �� °l Address Z l DSS <br /> Business Name DBA} Address <br /> aOwner_ } <br /> J,Firm Partners, Addresses and Telephone Numbers <br /> or 19 Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. �u Date <br /> - -' Title <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Ik Gal.,Weights & Measures No. <br /> Capacity <br /> a <br /> Equipment Parking Address <br /> w <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 7 <br /> I <br /> 4 No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> q. ANITATION PERMIT f <br /> Job Address/Location �' <br /> — Address <br /> Owner <br /> 11 SEPTIC TANK 11 CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> V <br /> ,.PERMANENT ❑ TEMPORARY ❑ NEW ,REPAIR <br /> OTHER � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> $. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> h <br /> I <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 r nd r ula ' f the an Joa uin Local Health District. <br /> { <br /> APPLICANT'S SIGNATURE X <br /> 1oil <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Ja ary 1 ❑ July 1 &Receiv dEB I J y 31 <br /> ! BILLING REMITTANCE AMOUNT DUE CHE E <br /> BASE EXPLANATION DATE DATE REMITT D AMOUNT <br /> Es27 <br /> C+ FEE <br /> L LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> { <br /> D `1 <br /> R201 <br /> eceived by Date <br /> Receipt Nu. Pel'mit o, issue ce Date M iced pelivered <br /> APPLICANT—RETURN ALL COPIES TOi ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009. STOCKTON,CA 95 <br />