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—Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> (Far Non-Transterable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ~ <br /> ' LIQUID WASTE <br /> Application is reby made W carryon ousiness in the'urisdictional area of thpliIquin Local ealth Di rict Ld <br /> wBusiness Name (DBA) • Address <br /> aOwner Address <br /> t J,Firm Partners, Addresses aAeleoneiI,N bers <br /> a. Business Telephone No. 0 Emergency Telephone No. <br /> a � <br /> Contractor Licence No. f <br /> Applicants Name (Flint) JAI <br /> y'q Title <br /> I 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 Y, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> ll1 Serial No. I CAL. License No. CAL. License Renewal No. <br /> F Capacity Gal:E Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <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 cation Test Date/Time <br /> 4. SANITATION PERMITl . t <br /> Job Address/Location r J <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 0-LEACHING FIELD XSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site O� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f I hereby certify that I have prepared this application and that the ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules e i n of the n oaqui al 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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE" EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> E FEE S F� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> !a � 1 _lo-to <br /> Received by- - Date- 1 Receipt No. Permit No lssu nce Dae - -Mailed Delivered I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES – 1601 E.HAZELTON-AVE.,P.O.Box 2003 STOCKTON,'A 95201 <br />