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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ]2 6 APPLICATION <br /> f- �' +' �U! (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicata h reby m �etory on us Hess in the jurisdictional area of San Jca n al Hea Distn t <br /> O Business Name (DBA) Address c�r � h�, <br /> z Owner ' Address <br /> C <br /> Firm Partners, Addresses and el ho mbers <br /> CL <br /> Business Telephone No, Emergency Telephone Na. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title Date T <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <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 No. CAL. License No. CAL. License Renewal No. <br /> 4 <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPERYARD <br /> t y <br /> t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST F <br /> R.S. or R.G.E. Name :.t- R.S. or R.C.E. No. I <br /> Test Location, Test Date/Time <br /> 4. ❑ SANITATION PERMI .r <br /> Job Addres ocation <br /> Owner t r Address y <br /> ❑ SEPTIC TANK ❑ CESSPOOL A LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> WPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction " Disposal Site ' <br /> No. of Units � Equipment Storage/Cleaning Location(s)-i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified v <br /> Plant Location 1 <br /> Plant Capacity No. Units Served t <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t , <br /> mak"' '' ''^ '• <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. _ <br /> r # <br /> I hereby certify that I have prepared this applicati an that the work will be done I hccordance with San Joaquin County <br /> ordinances, state laws, and rule u at th an aqui ocal Health D' 4t. i <br /> APPLICANT'S SIGNATURE X J �r <br /> L 3 <br /> y <br /> FOR DEPARTNT ONLY <br /> Fee Is'Due: ❑ ANNUALLY ❑ PER UNIT <br /> El SITE ❑ EACH January I & <br /> Received By January 31 ❑ July 1 &Received By July 31 <br /> R/ I k REMIT <br /> a BILLING MITTANCE $ AMOUNT DUE CHECKED <br /> ' BASE EXPLANATION DATE DAT£ REMITTED r AMOUNT <br /> � O <br /> FEE V. 4 � —S f <br /> LESS # <br /> PRORATIONt. <br /> PLUS <br /> PENALTY <br /> `e f <br /> OTHER <br /> OTHER t <br /> Received by Date-" Receipt No Permit No, Issuapfce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />