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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 /> LIQUID WASTE <br /> Application Is h e m to r on u ess I the jurisdictional area of t quin alth <br /> F Business Name (DBA) - %� � � S Address <br /> aOwner Address <br /> J Firm Partners, Addresses and TeP=Vers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information C/) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal NO. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <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 /> Te cation Test Date/Time <br /> 4. SANITATION PER T }� j <br /> Job Address/)p tion _ f+l/1 + <br /> �Ow er �/ Addr ss <br /> SEPTIC.TANK ❑ CESSPOOL .LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑"REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 s <br /> Type Construction Disposal Site -� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ <br /> Operator Name ` Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this ap lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s and r u t ons of t an oaqui cal Health District. ' <br /> APPLICANT'S SIGNATURE X + <br /> 31 <br /> Y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ €ACH ❑ January 1 &Received By Januar 316_Jk&&/Received By July 31 <br /> } BILLING REMITTANCE $ REMIT <br /> r BASE EXPLANATION PATE DATE REMITTED A LINT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r ;kx - <br /> OTHER YAN <br /> OTHER Y <br /> -3 <br /> jived by Date Receipt No. ermit No. r issuance Dae Mailed • Delivered <br /> JCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />