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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> (For Non-Transferable,`Revodatile, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> J LIQUID WASTE <br /> Application is her3rby made to carry, n business in the jurisdictional area of the San Joaquin Local Heal h District-. : <br /> Business Name (DBA) - -�� Address .d <br /> i Owner. I Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �� Emergency Telephone No.. �'• <br /> Contractor Licence No. (g���l <br /> L Applicants Name (Print) Title .Date. <br /> ` p03 <br /> Please check Applicable Category (1-7)and Fill in the Required Information w s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 :�L Disposal Sites _.._.._..: .... <br /> Description(Make/Yr., Color) I <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 Chemical Toilets Stored . <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIJ / t <br /> Job Address/Location ljl/ <br /> Owner Address ' <br /> ❑ SEPTIC TANK ❑ CESSP L - ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGEPhANT <br /> 1:1 PERMANENT ❑ TEMPORARY 1:1 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 I 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. F A <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that t e work will be done ir`-accordance with San Joaquin County w <br /> ordinances, state laws d les and regulations of th uin°Local Health.District. 00, <br /> APPLICANT'S SIGNATURE- All <br /> 11{f FOR DEPARTMENT.USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER NIT ❑ PER SITE - ❑ EACH ❑ January 1 &Received By January 31 Cl July 1 &Received By July 31 r <br /> REMIT <br /> BILLING REMITTANCE $ t <br /> AMOUNT DUE GHECKEp <br /> BASE EXPLANATION _ DATE DATE REMITTED .. <br /> AMOUNT <br /> FEE <br /> LESS / fJ <br /> PRORATION ' s <br /> PLUS <br /> PENALTY .. <br /> OTHER <br /> OTHER �. <br /> r Received by Date j Receipt No. Permit Noiss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009' STOCKTON,CA 95201 <br />