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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 /> V� LIQUID WASTE <br /> Applicat' is hereby made to cW on busines n the jurisdictional area of the San Joaquin Loc ealth Di Ict <br /> HBusiness Name (DBA)CAking i � - Address <br /> aOwner Address <br /> J Firm Partners, Addresses and le hone.Numbers <br /> a. Business Telephone No. S -2 Emergency Telephone No. <br /> Contractor Licence No. ''// tt.. 1 <br /> L Applicants Name (Print, -ft�/�OL� Title Date NCO m <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 J <br /> 4. ❑ SANITATION PERMIT <br /> Job Address Location �f • • <br /> IIK <br /> Owner A Rddress PACKAGEPLANT, <br /> ❑ S oEEFPc <br /> TIC TANK ❑ CESSPOOL LEACHING FIELD GE PIT <br /> IfeKPERMANENT ❑ TEMPORARY ❑ NL1l � FEPAIR <br /> ❑ OTHER 4 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 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 <br /> Operator Name 'Where Certified >' <br /> Plant Location dr° <br /> Plant Capacity No. Units Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. _ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify that ! have prepared this appli �nnd that t work will be done in accordance with San Joaquin County,+ <br /> ordinaries s �laWs,a ules an r gulati s Sa Jo in Lopal Health District. <br /> APPLICANT'S SIGNkfURE X ••C// <br /> -�.► <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8q-danuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE JS0%9, <br /> LESS <br /> PRORATION CO <br /> PLUS r <br /> PENALTY P _-.0- <br /> OTHER OTHER <br /> OTHER <br /> 3 01 _ <br /> Received by Date Receipt No. Permit No. lssu ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />