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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�ba o ryo sl �s in the jurisdictional area of the San Joaquin.Local Health Distri t�' a v \ Add ress l <br /> y Business Na,1nJa(DBA) <br /> z Owner er .L/ ��"� Address t <br /> J Firm Partners, Addresses and Telephone Numbs <br /> "Y <br /> IL <br /> a Business Telephone No. a Emergency Telephone No. <br /> -JContractor Licence No. t., - <br /> LApplicants Name (Print) —.Title M �-� � Date <br /> �..." a_I <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. <br /> 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. 1:1PERCOLATION TEST - { 9 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location € Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/LocoltiQ0 <br /> Owner <br /> ti Address �i4"� <br /> 11 SEPTIC TANK. 11CESSPOOL ❑.LEACHING.FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ,® NEW .9.<flEPAIR ..OTHER I'leX D 06 <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 1 <br /> Operator.Name T =Wherertified j <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ .LAUNDRY For July 1, -June 30, 19— <br /> 'SIZE: <br /> 9'SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. a <br /> '❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certifyat't"trave a d this a nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ul and re I sof ih San J- quin Lo al Health District. <br /> . , ti <br /> APPLICANT'S SIGNATUREX <br /> r �o oma. <br /> y _ FOR DEPARTMENT USE ONLY w <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By'January 31 ❑ July 1 &Received By July 31 <br /> _. IT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE, DATE REMITTED - AMOUNT <br /> � 4 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS S [ - <br /> PENALTY r - <br /> OTHER . <br /> OTHER <br /> 16 liq <br /> Received by Date! - Receipt No. Permit No, Issuatice uatqf Mailed Delivered ,. <br /> 'APPLICANT—RETURN ALL COPIES TO: —ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br />