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�_.. _ <br /> r Applications Will Be Processed When Submitted Properly Completed. Be Sure o ign e <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE I <br /> Applicati i hereby m e to carry on b iness.inthe ju 'sdictionaI area of the an Joaquin 6opal H th Distric <br /> F Business Name (DBA) �E 57- Address <br /> Address ip <br /> z OwnerI <br /> 2 Firm Partners, Addresses aAlee Numb s <br /> an'. Business Telephone No.. � Emergency Telephone No._ <br /> a <br /> Contractor Licence No. Date„w�— � 'J <br /> Applicants Name (Print) f Title <br /> Please check Applicable Category (1-7)and Fill in the Required Information Y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <br /> f Description(Make/Yr., Color)-- - CAL. License Renewal No. <br /> E Serial No. CAL. License No. <br /> Capacity . Gal., Weights & Measures,No. <br /> Equipment Parking Address s <br /> I 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. Na. <br /> R.S. or R.G.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMITt/rfCrE.. <br /> S 1 <br /> Job Address/L cation ' <br /> w Address <br /> SEPTIC TANK ESSPOOL LEACHING FIELD .❑ SEEPAGE PIT ❑ PACKAGE PLANT ' <br /> PERMANENT : ❑ TEMPORARY ❑ NEW ❑ REPAIR El OTHER <br /> R 5. ❑ CHEMICAUTOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site0.m -' <br /> F, No. of Units Equipment Storage/Cleaning-Location(s) + <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _� where Certified <br /> Operator Name <br /> r Plant Location <br /> II Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 " y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j <br /> I hereby certify that`I have prep red this application t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and re lations Joaqu L I H nth District. <br /> � l•��C,G�f/J <br /> APPLICANT'S SIGNATURE X t f <br /> t: <br /> I FOR DEPARTMENT USE ONLY <br /> . PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 C] July 1 &ReceiveRdEByl July 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> EXPLANATION <br /> BASE DATE DATE REMITTED AMOUNT <br /> FEE <br /> Ll <br /> LESS <br /> PRORATION - <br /> PLUS 4 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. Permit No. Issuan a Date Mailed Delivered <br /> Received by ? <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2 S CKTON,CA 2✓ <br /> _ it <br />