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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> n APPLICATION <br /> Y (For Non-Transferable, Revocable, and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio eroy' car on"ness in th is anal area of the oaqui.q Local alt istric <br /> rn Business Name ) f� Address Q , r <br /> z Owner 'i9—Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �i p <br /> a I' � dU <br /> Applicants Name (Print) Title Date, <br /> u � <br /> Please check Applicable Category(1-7)and Fill in the Required Intormai n r~ 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT IREGISTRATION (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 /> p <br /> Capacity �I Gal., Weights &Measures No. <br /> Equipment Parking Address I� <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST �I <br /> R.S. or R C.E. Name I R.S. or R.C.E. No. <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT II: <br /> Job Addres ocat;on I <br /> Owner Address G <br /> ❑ SEP IC TA K 1:11 CESSPOOL EACHING FIELD SEEPAGE PIT ❑ A AGE PLANT <br /> ❑ PERMA NT ❑ TEMPORARY ❑ NEW ❑REPAIR ❑ OTHER , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units I��' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLAINT For July 1, -June 30, 19 rn <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity �' No. Units Served ; <br /> 7. ❑ LAUNDRY For July 1, -Jui.a 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft1l1. ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance n+' h San Joaquin County <br /> ordinances, state laws, and rut d regulations of n aquin Local Health District. <br /> APPLICANT'SSIGNATUREX I� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑-ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ uary eceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMiTTA <br /> BASE _ EXPLANATION DATE ATE REMIT TED AMOUNT DUE CHECKED f <br /> AMOUNT <br /> FEE - L <br /> LESS �r <br /> PRORATION I <br /> PLUS '. <br /> PENALTY II <br /> � k <br /> OTHER <br /> OTHER 9' _ <br /> Received by Date g. Receipt No. - .-Permit No. Issuarf a Datla Mailed Delivered I.#: <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />