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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable;and Suspendable)_ SEPTAGE <br /> ENVIRONMENTAL HEALTH•PERMIT <br /> LIQUID WASTE <br /> Application ispereby made A carry, siness in the nsdictional area of the�9jn oa In Local/ye"It strict <br /> �iness Name{DBA) �_ _� Address-- �+ t i <br /> z Owner Address <br /> Firm Partners,Addresses and Teleph`o a Numbers <br /> CL Business Telephone No - 446��6 47 Emergency Telephone Nq. _._ <br /> Contractor Licence No. .. S _ <br /> !-Applicants Name (Print) r Title. 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,'-- 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. • f_ <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 /> Tesocation Test Date/Time <br /> , -... _ <br /> "• Y,i`: <br /> 4, �SANITATION PERMIT <br /> Job Address/ oc tion A <br /> Owner_-_tr�� x • IS14 C_ Address , Z �. �7� � <br /> ❑ SEPTIC TANK 1:1CESSP_OOL 13 LEACHING FIELD ❑ SEEPAGE PIT ❑�+PACKAGE PLANT <br /> 13PERMANENT" ElTEMPORARY 11 NEW REPAIR 1ZOTHER pf,#14) FEE o� <br /> S. 1:1CHEMICAL TOILETS For July 1, -June 30, 19 <br /> _ )e Construction t Disposal Site t <br /> of Units f Equipment Storage/Cleaning Location(s) t Irl No <br /> o. ❑ PACKAGE,TREATMENT PLANT . For July,1,-Juhesi0.`19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity t No Units Served t • ":� t <br /> 7. El LAUNDRY- For Ju1Y^1, =June 30 19 <br /> • i - _. . <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-, ❑ More Than 1',000 Sq, Ft. <br /> ❑ DRY CLEANING,Chemicals USed/AmounthA <br /> f hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i ordinedces state laws`,and rules d regulation of the S quln L ca Health District. <br /> APPLICANT'S SIGNATURE X`� <br /> t <br /> -1it, FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT Q PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 " <br /> REMIT <br /> BASE EXPLANATION „� BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r YI DATE -DATE REMITTED AMOUNT 1 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .- <br /> OTHER - <br /> OTHER <br /> t� 19: -:3 -r8-fit <br /> �Recewed by Date <br /> Receipt No. permit No. Issuance�g-� Date all Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERWCES 1601 E.HAZELTON AVE.,P,O_ ox 2009 •STOCKTON,CA 95201 - <br />