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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 /> Applicat' Is herebymactPtocarry�usiness' he jurisdictional area ofthe.Sa Joa«ui cal h is <br /> ,7 Business Name (DBA /tE C�ptJir � { <br /> Address <br /> a Owner N Address <br /> 7 Firm Partners, Addresses and T Ie Numbers T <br /> CL <br /> Business Telephone No. SZ Emergency Telephone N <br /> Contractor Licence No. <br /> �Applicants Name (Print <br /> Title.• Date f` <br /> Please check Applicable Category(1-7) and.Fl11 in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT.REGISTRATION (FOR EACH VEHICLE) .,.w <br /> For July 1, • - June 30, 19Disposal Sites i W <br /> - �- - — <br /> I <br /> Description(Make/Yr., Color) Y. %� Y <br /> �^^ <br /> Serial No. CAL:f License=hto-. CAL. License Renewa....._liNo. <br /> Capacity Gal., Weights' 1Measures No.j <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD f ¢5 <br /> For July 1, June 30, 19 _ • <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored r A .3 <br /> 3. '❑ PERCOLATION TEST ± - ! <br /> R.S. or R.C.E. Nameiv <br /> R.S. or R.C.E. No. f <br /> Test Location s <br /> Test Date/Time I <br /> 4. ❑ SANITATION PERMI F <br /> Job Address tion /• �E <br /> Owner ' <br /> -Address <br /> ,❑ S TIC TANK ❑ CESSPOOL 8 LEACHING FIELD. 153�PAGE-PI0--PAC- GE-PLANT- <br /> MIT- � v <br /> PERMANENT ❑ TEMPORARY UL-PtIm ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19X. <br /> Type Construction c <br /> Disposal Site <br /> No. of Unitssyr G r Y, <br /> .E�quipjnem Storage/Clean'ir g Location(s) ry`'� 1► -�- , <br /> 6. ❑ PACKAGE TREATMENT PLANT For J4 1.,--June 30, 19' <br /> Operator Name <br /> P Where Certified "" _ <br /> Plant Location <br /> f <br /> Plant Capacity (. l`� t ° ° No. Units'Served O# <br /> T. El LAUNDRY For July 1, -June 30, 19 S <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Than.•1,000 Sq: Ft. <br /> a " 3 <br /> ❑ DRY CLEANING, Chemicals UsedL*a,9y}nt/Mo. <br /> N. <br /> hereby certify that I hav r red this application and that t 'will be done in accordance with San Joaquin County <br /> ordinanceestate laws,a s and regulations of the <br /> uiD L I Wealth District. <br /> 4. <br /> APPLICANT' r <br /> FOR 6EPARTMENT USEONLY1 <br /> Fee Is Due: 13,ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 8,Received By July 31 <br /> BILLING REMITTANCE REMIT 7 <br /> - BASE EXPLANATION AMOUNT DUE CHECKED <br /> REMITTED AMOUNT <br /> FEET–. _• - <br /> LESS i <br /> PRORATION F <br /> PLUS <br /> PENALTY` <br /> OTHER _ �; . 1, , 's#•• �$ •x'.,....,.o <br /> OTHER F <br /> 1 S137Received by Date Receipt No. Permit No. tssu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/sERYICEs 1601 AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />