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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) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat on is hereby made to carry on bLiqiness in jhe jurisdictional area of the an Jo/a�uin Loll He h Istrict —t— <br /> aBusiness Name (DBA) Lam .- � X =- AddressC+ `� � I / <br /> iOwner_ Address. �.- <br /> Y Firm Partners, Address4an. Telephone. Numbersa. Business TelephoneNoContractor Licence No.Applicants Name (Print __— Title to <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 <br /> olor) --Serial No. _ CAL. License No. _- CAL. License Renewal No. <br /> Capacity 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 ----- - <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER IT <br /> Job Address/Location - <br /> Owner Address <br /> SEF�I,TANK C3CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PEA NT ❑ TEMPORARY EW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -� ne 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> 6.- ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 __ <br /> Where Certified <br /> Operator Name -- <br /> Plant Location --------- <br /> Plant Capacity —_ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 —. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DFtY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify th�hprepared t application a that the work will be done in accordance with San Joaquin County <br /> ordinances, st la , �f1d reg ation of he an Joa L I Health District. <br /> APPLICANT'S SIGNATURE X l <br /> FOR DEPARTMENT.USE ONLY <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 eceived By January 31 ❑ my 1 8 e By July 31 <br /> — REMIT <br /> BASE EXPLANATION BILLING REMITTANCE 0 T DUE CHECKED <br /> DATE DATE !REM ED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY — <br /> OTHER — <br /> OTHER 1 --- <br /> l Received by Date Receipt N. Permit No Issuance Uaie Mailed Delivered <br /> 1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.11A2ELTON AVE.,V.O.Bo[2009 STOCKTON,CA 95 <br />