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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. a - <br /> I� APPLICATION <br /> f (For Non-Transferable,Revocable,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE' <br /> Applicat'on is hereby made to rry on b iness in he jurisdictional area of the. an Joa uin.Loc I He h District <br /> y Business Name (DBA) C �.� E Address <br /> aOwner - Addres .., t, Y <br /> J Firm Partners, Addresses a Telephone Numbers T ' <br /> aBusiness Telephone No. Emergency Telephone No. `I <br /> Contractor Licence No. <br /> - i <br /> Applicants,Name (Print) �-. Title D to <br /> • µ <br /> Please check Applicable Category (1-7)and Fill Fin the Required.lnformation <br /> y1.j ❑ .PUMPER VEHICLE'PERMifFIEGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 -Disposal Sites- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. Lia se No`- I eCAL. License Renewal No. <br /> Capacity-- Gal.-,-Weights--&-Measures-No.---^ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD li - <br /> For July 1, June 30, 19 u :d <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored <br /> 3..❑ PERCOLATION TEST <br /> R.S..or R.C.E. Name 4 R.S. or R.C.E. No. 4 <br /> Test!Location Test Date/Time <br /> 4. 0 SANITATION PER IT <br /> `Job Address_/Location <br /> Owner .:4INJ 3 A&6ss . . <br /> SE"IQ TtANK ❑ CESSPOOL' LEACHING FIELD''- `SEEPAGE PIT— PLANT { 1 <br /> PERMAIV9=NT ❑ TEMPORARY EW REPAIR ❑ OTHER i <br /> 5. 0 CH MICAL TOILETS For July 1, - ne 30, 19 <br /> Type Construction , Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) i ti <br /> a <br /> ,6:'-1jPACKAGE TREATMENT PLANT For July 1, -June <br /> DF ( <br /> perator Name Where Certified <br /> .Plani Location <br /> Pia Capacity No. Units Served " - <br /> 7..=0 LAUNDRY For-July 1, --June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. F0. ElMore Than 1,000 Sq. Ft. <br /> `❑rD'AY CLEANING, Chemicals Used/Amount/Mo. <br /> v I'h'e�eby certify that I h prepared tiffs application a that the work will be d a'in accordance with San Joaquin County <br /> ?-� ordinances, st laws, a d r dreg lation of he n Joa L I Wealth Distric#. tf+ <br /> T i T- - ,- <br /> APPLICANT'S SIGNATURE <br /> TP <br /> II # <br /> I!' FOR pEPART,INENT[USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH r❑ January 1 &Deceived By January 31 ❑ my 1 & e By July,31 e <br /> REMIT #p <br /> BASE EXPLANATION BILLING REMITTANCE f F ' <br /> r- O T DUE CHECKED t <br /> - DATE DATE F1EM ED A A AMOUNTR <br /> it <br /> FEE .w. - <br /> LESS F <br /> PRORATIONPLUS <br /> PENALTY -�' <br /> OTHERk <br /> OTHERi <br /> Received by - Date ?Si Receipt.-No. spa Permit NoIssuancDate Mailed Deliveredl <br /> z , <br /> - APPLICANT-RETURN ALL COPIES'�TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1601 E.IEL <br /> iAZTON AVE.,P.O.Boa 2009- STOGKTON,CA 95201 -- <br /> I. <br /> !I 1 <br />