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r :Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �,� A APPLICATION t ` <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTALAEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applica is herebyAIGZA <br /> a tp carryo usiness in the• risdictional area of t J�1 -oaqui :al th Distric � <br /> OY <br /> Business Name {DBA Address c. — <br /> aOwner Address <br /> i Firm Partners, Addresses and Ife Numbers <br /> a. Business Telephone No. —a � �S Emergency Telephone No. <br /> Contractor Licence No. " <br /> LApplicants Name {P O Title Date � Q <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. Cl PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July,1, June 30, 19 Disposal Sites \\\- <br /> Description(Make/Yr., Color) ,1. <br /> 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 /> i No. of Vehicles''Stored-- - ' <br /> No.'of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 4 <br /> R.S. or R.C.E. Name + �" ':.,, �.-_'R.S.`or R.C.E No. <br /> w Test Date/Time�- .� <br /> Test Location <br /> 4. ❑ SANITATION PE I s t 1� <br /> Job Addre ocation z � �`r" Y' <br /> OwnerAddress <br /> ❑ SEPTIC TANK ❑ CESSPOOL ` LEACHINb FIELD 2 ASEEPAGE PIT ❑ PAC AG PLANT <br /> / PERMANENT ❑ TEMPORARY [:],NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June,30, 19 <br /> Type Construction Disposal Site .. " <br /> No. of Unitslob <br /> Equlpment Storage/Cleaning LocatlonCA <br /> (s) <br /> 6. ❑ PACKAGE-TREATMENT PLANT For July 1, -'June 30, 19 <br /> Operator Name r - Where Certified �• <br /> Plant'Locatlon <br /> Plant Capacity No. Units Servedkti <br /> 7. ❑ LAUNRRY-^For'July 1, -June 30,:19 � <br /> SIZE: ❑ Less Than 1,000 Sq. Ft�,- ❑rNtore Than`111 0 <br /> •,000 Sq-Ft. } <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Z <br /> I hereby certify that I have prepa this app tl cation and a work will'be done in accordance with San Joaquin County,, <br /> ordinances, state laws, and nd regulations o u' < W-I Health'District: ' <br /> s` f <br /> APPLICANT'S SIGNAT - - - <br /> x~ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: i❑ ANNUALLY ❑ PER UNIT El SITE 11EACH C3January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> p <br /> ,...- BILLING REMITTANCE REMIT( <br /> S _ <br /> BASE EXPLANATION AMOUNT DG <br /> UE HEGI� DATE --DATE-. --REMITTED---.�- - R AM1M1OLj <br /> NT <br /> 4FEE ` S <br /> LESS <br /> r PRORATION Kjow <br /> I <br /> PLUS I sx4 <br /> PENALTY <br /> OTHER <br /> l• OTHER <br /> s'8 <br /> Received ey - Date Receipt No. Permit No I suance Vale -Mailed Delivered <br /> APPLICANT—RE ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O:Box 2009 - STOCKTON,CA 95201 <br /> �GIA6,A)ZA4- /3 <br />