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Applications Will Be Processed When Submitted Property 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 />Application Is 170eby made to c�a/ry on b-siness in the'urisdictionalarea of th n aquin Loa ealth itis <br />F Business Name (DBA) %¢f�� /� %'t 8/�f �� j{/G - Address-, 1 11I � +� ��94. S� <br />-9 Owner Address <br />J Firm Partners, AddressAand hone N mba Business Telephone NoEmergency Telephone No. <br />Contractor Licence No._5 <br />LApplicants Name (PrintTitle , Date T <br />Please check Applicable Category (1-7)'and Fill in the Required Informati <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, - -June 30, 19y <br />- Disposal Sites - <br />_ <br />Description (Make/Yr., Color) <br />Serial No. s x .. -CAL. License No.,•CAL. <br />License Renewal No.. <br />Capacity Gal., Weights &'j , su(es No_ . _.j.~ <br />BILLING REMITTANCE $ <br />Equipment Parking Address ------- <br />REMIT <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 E' ` : -► <br />DATE DATE REMITTED <br />No_ of Vehicles Stored �, i �• •r <br />'��, i <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST <br />R.S. or R.C.E. Name J -- R.S. or R.C.E. No. <br />Testt�cation Test Date/Time <br />FEE <br />4. 14 SANITATION PERMIT <br />z <br />Job Addr ocation <br />e <br />O ner SAddress r <br />7 i <br />SEPTIC TANK Q CESSPOOL LEACHING FIELD FISEEPAGE PIT <br />❑ PACKAGE PLANT <br />PERMANENT ❑ TEMPORARY lir NEW ❑ REPAIR <br />❑ OTHER <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />LESS <br />Type Construction Disposal Site I <br />a <br />No. of Units Equipment Storage/Cleaning toeation(s) ; <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30,,19 t <br />a <br />Operator Name <br />Where Certified <br />Plant Location <br />) <br />Plant Capacity No. Units Served <br />PLUS <br />7. ❑ LAUNDRY - For July 1, - June 30, 19 <br />SIZE: ❑ Less Than 1,000 Sq. Ft., , ❑ More Aftk.1;000 Sq. Ft. <br />.-- CLEANING, Chemicals Used/Amount/Mo, ' <br />PENALTY <br />:DRY <br />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 r sand re ul ions of th Jca u/iA/Local Health District. <br />APPLICANT'S SIGNATURE X <br />,/ <br />FOR DEPARTMENT USE ONLY <br />r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PFR SITS• Fl FArW F1 ,,,....,.... , e a --- :.. "...__- __..,. <br />rn <br />lb 7 <br />Received by Date Receipt No. Permit No. 1 suance a Marled Delivered <br />— APPLICANT—RETURN ALL COPIES Tb: '.ENVIRONMENTAL HEALTH PERMITMERVICES - 1601 E. HAYt:LTON AVE., P.O. B.I. 2000 STOCKTON, CA 95201 <br />BASE <br />EXPLANATION <br />BILLING REMITTANCE $ <br />REMIT <br />DATE DATE REMITTED <br />AMOUNT DUE <br />CHECKED <br />AMOUNT <br />FEE <br />OO <br />LESS <br />' <br />PRORATION <br />C <br />_ 6� <br />O <br />PLUS <br />I <br />PENALTY <br />OTHER <br />OTHER <br />4 <br />lb 7 <br />Received by Date Receipt No. Permit No. 1 suance a Marled Delivered <br />— APPLICANT—RETURN ALL COPIES Tb: '.ENVIRONMENTAL HEALTH PERMITMERVICES - 1601 E. HAYt:LTON AVE., P.O. B.I. 2000 STOCKTON, CA 95201 <br />