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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r LIQUID WASTE <br /> Applica o Is hereb ma t r on busine he urisdictional area of t an Joaq 'n oval H h Di tri t k <br /> OF Business Name (DBA} � �'� f :; Address <br /> z Owner <br /> Address <br /> J Firm Partners, Addresses an&1phone Numbers <br /> a .- - - Emergency Telepho�N­o­ <br /> M <br /> Business Telephone No, <br /> Contractor Licence No. <br /> L Applicants Name(Print) Tiile Date <br /> Please check Applicable Category-(1-7)and Fill in the Required Information 1f <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _) <br /> For July 1, -June 30, 19 - Disposal Sites- - 1 <br /> f <br /> Description(Make/Yr., Color) <br /> Serial No. T _ CAL. No. CAL. License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> p y <br /> Equipment Parking Address + <br /> 2. ❑ PUMPER YARD <br /> For Jul 1, June 30, 19 • i , ty� ..-t } <br /> No. of Vehicles Stored t <br /> No. of Chemical Toilets Sfored f f <br /> 3. ❑ PERCOLATION TEST.. <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 'I�. F <br /> 4 ` ANiTATION P I I 3 0�� . <br /> Job Address41f.-J& <br /> ocation l� g r <br /> Owner-e' �i'" `1 � � Address ; <br /> /SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑'PACKAGE PLANT <br /> 4s�NERPU HENT ❑ TEMPORARY XNEW []-REPAIR <br /> ❑tOTHER <br /> S. O,CHEMICAL TOILETS For July 1, June 30, 19—' <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGETTREATMENT PLANT For July 1, -June 30, 19 I i 'F <br /> t `r Where Certified <br /> Operator Name - r <br /> Plant Location <br /> s <br /> ' F No. Units Served <br /> Plant Capacity � <br /> 7. ❑.LAUNDRY ;For July 1, --June 30, 19- <br /> -'1,000 <br /> 0, 19 r ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> . - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. , <br />�, s is fo„�- �' t•r� � ,. � <br /> I hereby certify that.1 have prepared this a plicati n a t t the work,will-be done in accordance with San Joaquin County <br /> r ordinances, state laws, and rules egu a 'o o t an J aquin ocaI Health District. <br /> !APPLICANT'S SIGNATURE X <br /> .s Vim' �•�CI�► [/�'] <br /> FOR.DEPARTMENT USE ONLY <br /> * Fee IS flue[❑ ANNUALLY. ❑ PER UNIT El PER SITE ; El EAC �_❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> . REMIT <br /> w NATIO`IN BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> k -•'�^ RASE EXPLANDATE DATE REMITTED AMOUNT <br /> + FEE <br /> LESS v <br /> PRORATION F~ 1 <br /> PLUS <br /> ate* PENALTY i <br /> v <br /> OTHER k <br /> f OTHER .. <br /> Received b.y Dale Receipt No. Permit No. Issuance ate Mailed Delivered I <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON E.,P.O.Box 2009 STOCKTON,CA 96201 <br /> s , <br />