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Applicat ns Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> `" ��` S, APPLICATION S! <br /> 11 <br /> r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE j . <br /> r <br /> 41 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE `r Q <br /> A{l`plicatio iss h reby ede to ca0t1 b si ss in the jurisdictional area of the San,Joaquiri'Lo�c�al Health Dis t <br /> NBusiness.Name (DBA) ` -�� Cc Address, <br /> ~ "� Address ? 0 <br /> a Owner— <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No, <br /> Emergency Telephone No. <br /> -J Contractor Licence No. <br /> L Applicants Name (Print) C-le 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 /> t <br /> Equipment Parking Address <br /> 2. ElPUMPER YARD 3 <br /> For July 1, June 30, 19 l <br /> No. of Vehicles Stored ; <br /> ,'No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. N <br /> Test Location Test Date/Time o�) <br /> 4. I SANITATION PERMIT o J <br /> Job Addr e ovation e ' er - <br /> ' <br /> Owner Address <br /> 0 SEPTIC TANK ❑ CESSPOOL MLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT fi <br /> ff-PERMANIENT ❑ 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) n <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. FL ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> i <br /> I hereby certify that I have prepared this a lication and that the work will be done in accordance with San Joaquin County <br /> - ordinances, state laws, and rule nd regu ti o he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE,X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH -.❑ January 1 & i d By January 31 ❑ July 1 &deceived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING � REMITTANCE � $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED- AMDUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER G <br /> —7�',Ory 1 1 ' <br /> �c. S <br /> Received by :6) Receipt No Permit No Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />