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vv 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 car on business in a jurisdictional area of the Sa Joaquin Local Health istrict <br /> N Business Na*Addresses. <br /> A) Address <br /> aOwner Address <br /> Firm Partner , and Telephone Nu bers <br /> aBusiness Telephone No. �, �� Emergency Telephone No. a d <br /> Contractor Licence No. <br /> 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., Calor) <br /> Serial No. CAL. License No. GAL. Lice Ise Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> 5 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ' lI <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> i <br /> Job Address/Location x4e e �� n <br /> � ' <br /> Owner -�.r�%= l Address—/� <br /> ❑ <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ®g PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 13TEMPORARY E] NEW la REPAIR 11 OTHER C <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 /> i, 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 rules.,And regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <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 /> REMIT <br /> ( BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> qSFEE S c ` a <br /> 4 LESS <br /> f PRORATION Mr <br /> ' PLUS <br /> r PENALTY <br /> OTHER <br /> f <br /> OTHER <br /> 133(,3 <br /> �� 1 <br /> Received by Date Receipt No. Permit Nc fssuancelDate Mailed Delivered <br /> j APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />