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`; � ApplicatJons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> ' _ ` '�� APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> `--ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE T <br /> Application is herebymade to car on bus' ess'n the area of theja Joa In Local Health Dist t <br /> rn Business Name (DBA) Poe carry I -� Address.;` � AJ <br /> l z Owner Address --..-.. - <br /> Firm Partners, Addresses and Telephone Numbers --- <br /> 5. Business Telephone No. p `9 �7,.. Emergency Telephone No. <br /> Contractor Licence No. - �w <br /> LApplicants Name (Print) Title, =i49 Date <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.' m June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD;i' <br /> For July 1-, . _ June 30, 19 ; ",k V's i,`• -ak's <br /> No. of Vehicle$Stored ' <br /> No. of Chemical Toilets Stored , <br /> 3. -❑ PERCOLATION TEST <br /> i <br /> sx <br /> � t <br /> y 4 . <br /> R.S, or R.C.E. Name R.S. or R.C.E. No. � _ <br /> Test Location Test Date/Time 4 �� <br /> 4. SANITATION PERNII <br /> Job Address/ ocation A <br /> Owner ` - -` Address ; <br /> ❑ SEPTIC TANK > ❑ CESSPOOL R-,CE__AC HING FIELD R-9�EPAGE PIT El PACKAGE PLANT <br /> 9-PERMANENT,_- ❑ TEMPORARY ❑ NEW, `�i '• 2-Fi15-PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) -ACT., <br /> 6. 1:1 PACKAGE TREATMENT PLANT For July 1, -June-30, 19,E <br /> Operator Name _ _ _= Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7.1❑ LAUNDRY For,July.1, =June-30,)9 <br /> SIZE: ❑•.Less Than,1,000 Sq. Ft., ❑ More;Tfaan T;OOD 5q'.Ft. <br /> ❑ DRYING,Chl3mica(s`Used/Amount/Mo:`' ' <br /> 4 <br /> 4 <br /> 1-hereby certify that I h prepared this a plication an afthe r will a done iri accordance with.San Joaquin County <br /> 6,ordioances,'state law and reg Ions of th n Jo in cal He Ith District. <br /> `�:.APPbGArNT'S SIGNATURE <br /> , <br /> -FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE —DATE REMITTED AMOUNT <br /> FEE <br /> LESS r �j -`'• . --. �' <br /> PRORATION g <br /> PLUS <br /> PENALTY - - <br /> f <br /> OTHER <br /> f <br /> /OTHER <br /> i' <br /> r ' <br /> Received by - Date Receipt No Permit No Issuance Date Mailed Delivered <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> Y <br /> .,:bs <br />