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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. 01-11 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 3 EN IRONMENTAL HEALTH PERMIT <br /> 4 IQUID WASTE l -230 l <br /> Applica ion Is hereby made to car on busi ss in th�e�'urisdictional area of the San Joaquin cal Health Dista t <br /> yBusines Name (DBA) 6_M_ t L T'1_Q__ Address L <br /> aOwner _ L� l Address <br /> Firm Partners, Addresses agg Telephone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) -LTitle Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �1 <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 /> '4: v <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. ,r <br /> Test Location Testate/Yime f 111FA <br /> 4. ❑ SANITATION PERMIT �� p k-^! 5 U . <br /> Job Address/Location - - <br /> 7 <br /> Owner 7m 5� �� Address xSDI <br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD ,13SE�PAGE PIT <br /> �+ ❑ PACKAGE PLANT. Y �. <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ RI PALR ❑ OTHER I/V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (P <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 <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 herebyq'rtlfy� <br /> repar this applicati n and that the work will be ct a in accordance with San Joaquin County <br /> ordinanc , le an re ati ns he San aq in Local Heal District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPVT USE ONLY <br /> Fee Is Due: 13ANNUALLY ElPER UNIT 11PER SITE 13 ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION 8 NG REMITTANCE $ AMOUNT DUE CHECKED <br /> TE DATE REMITTED AMOUNT <br /> FEE S 8 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S <br /> Received by Obte Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 - <br />