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''�... AApplications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transterable, Revocable, and Suspendable) SEPTAGE <br />' ENVIRONMENTAL HEALTH PERMIT <br /> I <br /> LIQUID WASTE <br /> Applicatio is hereby ma to on nes i he jurisdictional area of the San quin L al Health Dista <br /> Address , r s <br /> 4 Business e�DBA) 0 , <br /> z Address <br /> a Owner rc.1C c -7(,{",2 <br /> j Firm Partners, Rddresses and Telephone Numbers S <br /> ' a Business Telephone No. �-�� 33. Emergency Telephone No. <br /> Contractor Licence No. �xr _ Date r f <br /> - Title <br /> Applicants Name (Print) <br /> Please check Applicable Category (1 7)and Fill in the Required information 1 <br /> '1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. y <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 StoredNo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION.TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time v <br /> 4. ❑ISANITATION PERMIT r <br /> Job Addres Locati n v s�ty�_ <br /> Owner A�"LEACHING <br /> Address❑ SEPTIC T NK ❑ CESSPOOL: FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> '❑ PERMANENT ❑ TEMPORARY ❑ NEW .REPAIR ❑ OTHER '- CA) <br /> 444 5. ❑ CHEMICAL TOILETS For July 1, -June 30, i9 d <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/CleanirTg-Location(s) <br /> l i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30 19 Where Certified <br /> Operator Name y <br /> Plant Location , ~ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11 Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft. ; <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> .y <br /> I I hereby certify that I have prepared this appli io and that the work: <br /> be,done in accordance with San Joaquin County <br /> alth District. <br /> ordinances, state laws, and nd re ula n Joaquin Local He <br /> APPLICANT'S SIGNATUREXr <br /> FOR DEPARTMENT USE ONLY - <br /> rFee IS Due: ❑ AN ❑ PER UNIT ❑ PER SITE -❑ EACH ElJanuary 1 &Received By January 31 - ❑ July 1 &ReceiveRd'By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> - 1 DATE DATE RE Eb - AMOUNT <br /> FEE 5 ; - <br /> LESS <br /> ' PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER _ <br /> OTHER <br /> Date Receipt No. Permit`No Iss ante bat Mailed Delivered <br /> Received by' , <br /> 1601 E.HAZELTON AVE.,P.O:Box 2049 STOCKTON,CA 85201 <br /> APPLICANT-RETURN ALL COPIES TO,- ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />