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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> G _ APPLICATION <br /> (For Non-Transferable;Revocable,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEATH PtRMIT <br /> LIQUID WASTE <br /> t � - IWisdicApplication her y detocarry n bus ess in-the tional-area oft an aquin Loca ri <br /> oBusiness Name (DBA � pR-6 k 4 111.— r <br /> - Address W, ' <br /> z Owner __ Address <br /> Firm Partners, Addresses and Telep n umb s <br /> aBusiness,Telephone No. - Emergency Telephone.No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title.~ `>.[]ate 1 <br /> Please check Applicable Categ9ry,(1;-7) and Fill'in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30; 1.9 =-Disposal Sites <br /> Description(Make/Yr., Color), _ <br /> CAL. License No. CAL. License Renewal No. <br /> Serial 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 h <br /> R.S.or R.C.E.No. t <br /> R.S. or R.C.E. Name - <br /> Test Location' Test Date/Time <br /> 4. )(SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> �CSEP TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE-PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPA'IR '� OTHER RQC��+�, _ __ �y + <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 + F•G-�.irrTy/ pwd <br /> Type Construction *� :_; ,Disposal Site - 11 <br /> No. of Units Equipment Storage%Cleaning L-ocation(s)'""y <br /> 5. 1:1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19� �° Y . <br /> Operator Name k Where'Certified 1 <br /> Plant Location I <br /> �,' No. Units Served <br /> ? <br /> Plant Capacity � <br /> 7. ❑ LAUNDRY For July 1;-June 30,119 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑4Mbre Than 1,000 Sq. Ft.. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r' <br /> I hereby certify that I have prepared this application and that the worldwill-be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg I ions a Sa oaquin Lockal Health District. <br /> ,. T - <br /> APPLICANT'S SIGNATURE X - <br /> t � <br /> 1 41 <br /> i <br /> - FOR DEPARTMENT USE ONLY <br /> i Fee Is Due_: 0 ANNUALLY _❑_PER'UNIT 11 PER SITE El EACH '❑ January 1 &Received By January.,1, ❑ July 1 &Received By Juky 31 <br /> REMIT <br /> BILLING REMITTANCE - ' t <br /> BASE t EXPLANATION- AMOUNT DUE CHECKED <br /> DATE,+!--- -- DATE-�• y�.--•:•REMITTED.,,...:: .,... AMOUNT j <br /> r i qS <br /> [13 <br /> FEE <br /> LESS <br /> PRORATION s <br /> PLUS 'Y <br /> PENALTY <br /> OTHER k, 111 <br /> '..OTHER <br /> P k <br /> z <br /> 2 <br /> Received,by Date Receipt No. 3 (-j Permi No ' Is uance Date Mailed el7vered <br /> ., <br /> APPLICANT—RETURN ALL COPIES TO: FN -MENTAL HEALTH l?ERMIT/SERVICES •1601 E.HAZELTON Ave.,P.O.Bos 2009 STDCKTON,CA 95201 <br />