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I Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION / <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> s ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application,m'here ,by mad to carr n b s ess in the jurisdictional area of thSan Joaquin Lj}cal Health Distri t e <br /> Business Name (DBA) _ Address r�Q_-19O1(+l�"a <br /> aOwner Address. <br /> J Firm Partners, Addresses and I phon%u hers <br /> ILL — (�9 Emergency Telephone No. <br /> I Business Telephone No.. <br /> Contractor Licence No. <br /> Date <br /> Applicants Name (Print) s Title <br /> } Please check Applicable Category (1-7)and Fill in the Required Information y O <br /> ( 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 Disposal Sites <br /> Description(Mak&Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity ' Gal., Weights & Measures No. <br /> Equipment Parking Address'. k <br /> �i <br /> 2. 11 PUMPER YARD _ _ ° ~r' <br /> 30, 19 �.� - �is � <br /> For July 1, °°�_'•'"-June � 3 ; <br /> No�of-Vehicles Stored <br /> No:of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name _ _ <br /> R.S. or R.C.E.No. <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addr /Luca ' <br /> A dress <br /> Owner -. - <br /> ❑ SEPTIC TANK ❑ ESSPOOL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑-TEMPORARY; ❑ NEW REPAIR 11�OTHER'rDp"5;TEVnq t?IE �J�vGI1 <br /> .5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 . a*• �" s `� <br /> h �-y <br /> Type Construction Disposal Site <br /> No. of Units ' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANTI 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 /> y <br /> __ / <br /> 1 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 rules regulation of the 5 J aqui cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedBy July 31 <br /> REMIBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> V. <br /> s LESS <br /> i PRORATION <br /> PLUS <br /> r , PENALTY ✓' ��y✓� p <br /> "OTHER <br /> OTHER <br /> � Permit No. Issuan Date Mailed Delive d <br /> Received by Date Receipt No. <br /> 1601 E.HAZELTON AVE.,P.D.Box 2009 STOC TON,C 952111 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />