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Applications Will Be r en Submitted Properly Completed. Be Sure To Sign The Application. 4 <br /> - APPLICATION <br /> (For Non-Transferable,Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica 'on i hereb ade to carry on b ess in t jurisdictional area of the San Joaquin al a Ith i�trict <br /> y Business Name (DBA) ��w Tti"� - Address % — xyl - <br /> = <br /> z Owner„ - _54Me2 _ Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No: Emergency Telephone No. f . <br /> Contractor Licence No. <br /> Applicants Name (Print) -Xt A - Title M Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information , , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L <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 /> CapacityGal.,Weights & Measures No. I <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 <br /> 4. SANITATION PERMIT ' <br /> Job Address/Location <br /> OwnerAddress <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER t W <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 /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 I <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July i, -June 30,19 <br /> i <br /> SIZE: ❑ Less Than,1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <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, a rules and regulations of the San Joaquin Local Health District. , <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH _ ❑ January 1 &Received By January 31 El 1 &Received By Ju{y 31 <br /> .. - - _ _. <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEs t <br /> LESS <br /> PRORATION r " <br /> PLUS <br /> PENALTY - '• T <br /> OTHER - ,ll,Ve 9V <br /> OTHER- YLUe L11 <br /> m Lt <br /> Received"by IDate A Receipt No. Permit No. Issuance 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 />