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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <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 San Joaquin Local Health District ,+ <br /> yBusiness Name (DBA) f` Address �'y <br /> aOwner vV +"'" Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. r�+�`/� `1;f o',/:Y� Emergency Telephone No. <br /> Contractor Licence No. <br /> L 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 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 /> No. of hemical Toilets Stored <br /> 3. XERCOLATION TEST y; r <br /> R.S. or R.C.E. Name 1c. R.S. or R.C.E.No. <br /> Test Location 41k pts o Test Date/Time SU • Y 7— ZZ <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 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 /> Cl DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this applicat .pf an that the work yGjll a done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatior} th Joaquin oal ealth District. <br /> is <br /> APPLICANT'S SIGNATURE X r L <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> o o <br /> FEE �r /1LESS -Ict <br /> �' y <br /> PRORATION .2-0 .21 .12 T 2-1 <br /> PLUS <br /> PENALTY 4 <br /> OTHER <br /> OTHER ' <r <br /> ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />