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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> w (For Non-Transferable,`-Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> LIQUID WASTE <br /> Application ea?�rg¢ mad to c r n business in the jurisdictional area oft S n aquin L�cai H alth istrlQi <br /> (DBA) e �(/�S. �11:C. Address ZD/ <br /> OF Business Name DBA <br /> aOwner Address -- <br /> " Firm Partners, Addresses and T I h ne N m ers - <br /> J <br /> Business Telephone No a - Emergency Telephone No y . <br /> Contractor Licence No. 5321 i -3 24 <br /> Applicants Name (Print) Title r Date 'Z y <br /> Please check Applicable Category (1-7) and Fill in the Required Information w <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I ,� <br /> For July-1,— - z:' June 30 t19. Disposal Sites = — <br /> Description(Make/Yr., Color) b `- <br /> v.. <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 /> No. of Vehicles Stored <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 ocation Test Date/Time <br /> 4. J SANITATION PER IT <br /> - Job Add r /Location <br /> O ner (C,14 1Z 158 Address � <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD `SEEPAGE PIT ❑ PACKAGE PLANT, - <br /> ❑ <br /> PERMANENT ❑ TEMPORARY OTHER <br /> NEW ❑ REPAIR <br /> 5. 11 CHEMICAL TOILETS For July_1, -June 30, 19 4 _.. 1 <br /> Type Construction Disposal Site --.-Y - - <br /> No. of Units ? Equipment Storage/Cleaning Location(s) i <br /> S. ❑ PACKAGE TREATMENT PLANT' For July 1, -June 30,19 ` <br /> r Operator Name r" E Where Certified I <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 . 4 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. # <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. -I <br /> _ t k <br /> _JbF s S � I <br /> r \ •v„_ t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regul ti ns of the a Joaquin ocal Health District. t <br /> APPLICANT'S SIGNATURE X ! LAJ <br /> J. m ' <br /> 5 <br /> *. FOR DEPARTMENT USE ONLY_ <br /> Fee Is Due:r❑'nNruuALLY ❑ PER UNIT PER SITE' 1 ❑.EACH ❑ January 1 Received By January 31 July 1 &Receed By July 31 <br /> _._. _ y REMIT <br /> -BASE EXPLANATIONBILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATf 4.0 :* �,REMITTED 'AMOUNT <br /> FEEqS <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY .% <br /> OTHER <br /> OTHER <br /> . r <br /> Received by Date ,Receipt No, Permit No. IsfuanceJoatel Z Mail Delivered, <br /> F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -'1601 E.HAZELTON AVE.;P. ox 2009 STOCKTON,CA 85201 <br /> F <br /> i � <br />