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Applications WIII Be P ocessed When Submitted Properly Completed. Be SureToSign s <br /> APPLICATION <br /> (For Mon-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application reby made carryon bu mess in the juris ctional area of the �Joaquin I Health Dish` , <br /> '_Address— r"�r <br /> OF Business Nam BA <br /> z Owner Address <br /> d <br /> Firm Partners, Addresses and Telephone Numbers <br /> Sers Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. <br /> Title Date <br /> '-�--� <br /> L Applicants Name (Print) ` <br /> Please check Applicable Category (1-7) and Fill in the Required Int oration _h <br /> 1. IJ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) fV;L1� <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 /> Capacity' I 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 I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or R.5,E- L <br /> Test Lo tion Test Date/lime <br /> r <br /> i 4. ErSANITATION PERMIT,/�Q rl,� <br /> Job Address L cation `7 , <br /> Ow r Address <br /> ❑ CESSPOOL LEACHING FIELD S E PIT ❑ PACKAGE PLANT <br /> LI SEPTIG TANK ❑ OTHER <br /> PERMANENT <br /> ❑ ❑ TEMPORARY ❑ NEW REPAIR 4j <br /> i � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> k <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, Where Certified <br /> Operator Name ¢ <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ~ <br /> SIZE: 0 Less Than 1,000 Sq. Ft., ❑.More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> j <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules regulations of n J quin Local Health Di— <br /> strict.-APPLICANT'S SIGNATURE X <br /> 4 - <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> y Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EAC ,. ❑ January 1 S Received By January 31 July 1 &ReceivedREMITu y - <br /> € ' �'�` LL REMITTANCE $ AMOUNT DUE CHECKED <br /> '�BILLING,, <br /> BASE EXPLANATION DATE , DATE REMITTED AMOUNT <br /> FEE <br /> LESS ` <br /> PRORATION _ <br /> i <br /> PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> k Receipt No. Permit No Issuance Date Mailed Delivered <br /> Date <br /> a Received by isol E.KAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL NEALTR PERMITlSERYICES <br /> _mow. <br />