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-_.`. ..�.�_.....F <br /> r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appncatlon. <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatigigl hereby m e to carry on b�u`�iness in the ju sdictional area of the an Joaquin o al H th Distric <br /> yBusiness Name (DBA) C` Tc Address <br /> 10 i Owner Address e <br /> a <br /> 2 Firm Partners,Addresses and T le hone Numb 's <br /> M Business Telephone No. � Emergency Telephone No. <br /> a <br /> Contractor Licence No. Date2 <br /> Title <br /> L Applicants Name (Print) — <br /> ` Please check Applicable Category (1-7)and Fill in the Required Information <br /> t 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> f Description(Make/Yr., Color)- CAL. License Renewal No. <br /> E Serial No. CAL. Licerise No. <br /> Capacity Gal., Weights & Measures.No. <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> b: 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date <br /> Test Location /Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/l_ cation r <br /> W Address <br /> SEPTIC TANK, ESSPOOL LEACHING FIELD .❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> E] REPAIR O. OTHER <br /> PERMANENT: ❑ TEMPORARY 11 NEW r <br /> M1 _ <br /> 5. ❑ CHEMICAL'TOILETS For July 1, -June 30, 19 <br /> I Type Construction- Disposal Site w -" <br /> No. of Units Equipment Storage/Cleaning-Location(s) <br /> g. C1PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> r Plant Location <br /> fI No. Units Served <br /> Plant Capacity <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 /> ) <br /> I hereby certify that'I have prep red this application t the work will be done in accordance with San Joaquin County <br /> Joaqu L I H Ith.District. <br /> ordinances, state laws, and and re lations �. <br /> C APPLICANT'S SIGNATURE X ; <br /> r � . <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT ❑ PER SITE C3 EACH ❑ January 1 8 Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> Fee IS Due: ❑ ANNUALLY <br /> MIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 13ASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE L+� <br /> LESS <br /> PRORATION <br /> PLUS l <br /> PENALTY <br /> OTHER <br /> OTHER _00 <br /> Recei t No. Permit No. ssuan a Date Mailed Delivered <br /> Received by Date p �STOCKTOR,CA <br /> - ___.____-_.. .._.,�,...rn•.,�eoovirc[ tfi01 E.HAZELTON AVE.,P.O.Boi 2009 , <br />