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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> fi APPLICATION <br /> ' (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application er b made to carry QX6busmess in a jurisdictional area of the San Joaquin alth D' trict <br /> ,r Business Mom DBA) Address <br /> a Owner N Address5 ss <br /> w <br /> Firm Partners, Addresses d elephone Numbers <br /> a Business Telephone No. �' Emergency Telephone No. <br /> a - - <br /> �Contractor_Licence No. •-� - <br /> Applicants Name (Print) 'itle V L i - Date_ t <br /> Please check-Applicable Category (1-7)and Fill in the Required Information <br /> 1. 0 PUMPS_R-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 r <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 /> TestL�tion Test Date/Time <br /> 4. ® SANITATION PERMIT <br /> Job Address/Location <br /> Owner - Address <br /> 11 SEPTIC TANK 13 CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT " El PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARYE] NEW -" WOREPAIR ❑ OTHER <br /> S. 11CHEMICAL TOILETS�,For'July 1,-Ju a 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 d <br /> Operator Name Where Certified - - <br /> Plant Location <br /> Plant Capacity No, Units Served f <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 1 <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 repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a ru s and regulations of th San oaquin LaG6 Health Dist 'ct. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY -• <br /> Fee IS Due: 13ANNUALLY [IPER UNIT' 11PER SITE : ❑ EACH I:3 January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> -- REMIT I'yy <br /> BASE EXPLANATION BILLING REMITTANCE $ 1 <br /> AMOUNT pUE CHECKED <br /> DATE - DATE - REMITTED- AMOUNT J <br /> FEE a <br /> rJ <br /> LESS , <br /> PRORATION <br /> 5 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER - <br /> Received by ate I Receipt No. Permit No. Wance Date M C1606red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />