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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f- APPLICATION <br /> jj (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 1 �l 111 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appllcatio hereby mmad'e4to r usln ss in the jurisdictional area of t San Jo q I cal H t District f <br /> yBusiness Name (DBA) 5 Address ��3 �r <br /> aOwner— Address <br /> J Firm Partners, Addresses and T I p e Numb <br /> m Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. `- <br /> L Applicants Name (Print, Title Date X6_7 j <br /> Please check Applicable Category (1-7) and Fill in the Required Informationb� <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 R13newal No. <br /> Capacity Gal.,Weights R 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 Storeda <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name Imo_ R.S. okC.E..No: _ :sl ' <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addr S/ ocation <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD t ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ <br /> PERMANENT ❑ TEMPORARY 1 . ❑_ISEV4 ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,F June 30, 19 <br /> Type Constructioni I Disposal Site <br /> No. of Units - Equiprtl nt Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For Jti 1, -June 30, 19 ' • _. - ' <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity ! _ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000'�.'Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> I hereby certify that I have prepare ication d at t work will be done T' accordance with San Joaquin County <br /> ordinances, state laws, and rules a e I ns of t S Joa Local ealth Dis�ct <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENTU NLY <br /> Fee Is Due: El ANNUALLY [I PER UNIT 11P R SITE C1 EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING ITTANCE $ AMOUNT DUE CHECKED <br /> DATE Y DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER e <br /> 5) Fit <br /> Received by 3 Date Receipt No. Permit No. ssuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL .,P.O.Box 2009 STOCKTON,CA 9520 f <br />