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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 iabgLaLy mqd 9 to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Nam {DBA) (tiIQ Address <br /> a Ownerf�lllf� r� a Address � s a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. .5�4! Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) om e7 wry Title 0 L'i AJ k_ Date lQ 1 y <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 /> 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. 0 SANITATION PER / <br /> Job Address/Location—M40 <br /> Owner Imo• t4)t,kL-1,4A,_0 L Address Ce C/ A-z4 '(1-- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0 TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 O <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 —_ Where Certified E <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 th2 work will bedo in accordance with San Joaquin County <br /> ordinances, state laws, and rule d regulatlo s��Sa a in ocal alth istrict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 B Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTAN $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DAT REMITTED <br /> AMOUNT <br /> FEE A 4S E f <br /> LESS <br /> PRORATION <br /> PLUS j <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by to I Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />