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Applications Will Be Processed When Submitted Properly Completed. Be Sure 7o Sign The App Ica on. <br /> APPLICATION <br /> _ (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is I�e�eb ade try¢ rry oon usiness the jurisdictional area of the n Paquin La�c3�dHealth Di r ic� <br /> Address <br /> UF Business Name (DBA) <br /> in Address <br /> I Owner <br /> a <br /> Firm Partners, Addresses and Telephone Nu bers <br /> a Business Telephone No. Emergency Telephone No. <br /> ��f <br /> t <br /> a <br /> Contractor Licence No. Date O <br /> Sez Title <br /> L Applicants Name (Print) r <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 /> 's <br /> Description(Make/Yr.,Color) CAL. License Renewal No, <br /> Serial No. CAL. License 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 R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name r <br /> Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT 40 <br /> ! <br /> Job Addrss.Location fl <br /> Owner `�' � Address <br /> ❑ SEPTIC TANK 13 CESSPOOL FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ TEMPORARY yO NEW &C"IEPAIR 11OTHER <br /> �ERMANENT — <br /> f 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction No. of Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Na. Units Served <br /> Plant Capacity <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 /> t <br /> I hereby certify that I have prepared this applic nd tha the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru reg ti of t San oaquin cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: El ANNUALLY PER UNIT El PER SITE ❑ EACH ❑ January 1 8 Received 8y January 31 ❑ July 1 &Receiv REMIT By TUIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r L4 < a <br /> FEE dV <br /> I LESS O b <br /> PRORATION <br /> PLUS r7 <br /> t PENALTY <br /> k OTHER <br /> I <br /> OTHER <br /> 6-� <br /> Received by <br /> Date Receipt No. Permit No. lss e D Mailed Delivered <br /> I 1604 E.HAZEL AVE.,P.O.Box 2008 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />