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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneApplication ` <br /> APPLICATION F <br /> �- (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> fi LIQUID WASTE <br /> Application is, a eby made f ry on busine s in t jurisdictional area of the San Joaquin oc Health D'stri <br /> 9 Address <br /> Wr Business Jul me (DBA) <br /> Address <br /> a Owner <br /> y°'Firm Partners, Addresses and Telephone Numbers f <br /> aBusiness Telephone No. Emergency Telephone Na. <br /> Contractor Licence No. �G('1f� Date <br /> LApplicarits Name (Print) Title <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) CAL. License Renewal No. <br /> Serial No. '" _ CAL. License No. ) <br /> ) ) Gal„Weights & Measures No. <br /> Capacity i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,191 <br /> No. of Vehicles Stored <br /> I <br /> No. of Chemical Toilets Stored_ <br /> 3. ❑ PERCOLATION TEST. 11 <br /> � R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name - k <br /> s'' t 114- 1 Test Date/Time <br /> F Test Location ,: _ - <br /> 4. 29 SANITATION PERMIT <br /> Job Ad s/Location," <br /> S (' 4ddress <br /> Own r PACKAGE PL NT <br /> k 54 SEPTIC TANK ❑`CES OOL OLEACHING FIELD [J SEEP GE PIT . <br /> ❑ PERMANENT <br /> C3 TEMPORARY NEW 11 REPAIR <br /> 13 OTHER <br /> 5. © CHEMICAL TOILETS For July 1, June 30, 19 _ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Stora e/Cleaning Locations) <br /> I - . <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -Jun .30, 19 3 <br /> Where Certified <br /> Operator Name - <br /> Plant Location <br /> No. Units Served ' <br /> Plant Capacity " <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 y <br /> SIZE: C3 Less Than 1,000 Sq. Ft., ❑ More Than,00 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ---_- <br /> k <br /> I hereby certify that I have prepared this application and that the work will be done in.accordance with San Joaquin County <br /> ordinances, state Laws, an rifles and regulatio f t n Joaquin Lo Ith District. <br /> �- <br /> APPLICANT'S SIGNATURE X <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> -Fee IS.Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveR MITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6 O33�S <br /> 9 -7 9 - )Li9i <br /> Received by <br /> - •D to Receipt No ��Permit No. issuance Date � Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,� -�# <br />