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p 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 /> LIQUID WASTE <br /> Application ' e ade to c n business in the jurisdictional area of the San Jo qui oval Heal thiD iS4ric f <br /> Business - Address <br /> aOwnerame{D ) Address „ <br /> J Firm Partners, Addresses and Telephone Numbers ' <br /> I a Business Telephone No. _ Emergency Telephone No. <br /> �Contractor Licence No, - <br /> L Applicants Name (Print) Title 7Date_ -- <br />{ Please check Applicable Category (1-7)and FIJI In the Required Information.. . 9 _ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 -Disposal Sites <br /> Description(Make/Yr.,Color) <br /> I <br /> Serial No. CAL. License No. - CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. Q <br /> Equipment Parking Address 0 <br /> 2. ❑ PUMPER YARD <br /> For July 1, "June 30, 19 . 3 <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 /> TestLoc ption Test Date/Time <br /> �, <br /> 4. E�SANITATION PERMI <br /> Job Address/Locationd <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL O—LEACHING FIELD J4 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY .NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 3 — z4v <br /> , yL .3 33 '�C 2 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> .6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 *3I ._ 4 . <br /> Operator Name Where Certified <br /> Plant Location *N-,0�1' 4 ; <br /> � <br /> Plant Capacity �t p No,Uri6its 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 <br /> I hereby certify that I have prepa application d2that t ork'will be done cco an with San Joaquin County <br /> ordinances, state laws, d re lations t oaqu" Lo I Health D' ric <br /> APPLICANT'S SIGNATUREXIF <br /> FOR DEPARTMENT USE ONLY <br /> Fee 18�=DU@: ❑ P.NNUALLY;..-FA ®"PERF. T n S . <br /> _i a U ❑ PER SITE ❑ EACH*. . ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> '+ r k REMIT <br /> .'+A- ,"•C� t BILLING EMITTANCE $ <br /> _ BASE, :f PLANATION AMOUNT DUE CHECICEp <br /> - ' DATE'' TE REMITTED ,. - <br /> AMOUNT <br /> FEE > x" <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER T _ <br /> C7 <br /> Received by Date Receipt No. Permit No. i uance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br />