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Applications Will Be Processed When Submitted Properly <br /> �. APPLICATION <br /> (For Non-Transfiribie;Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL <br /> o ESTE TH'PERMIT <br /> Application is her made to car{y bLksiness in a LI jurisdictionalarea of <br /> Ae �n Joaquin Loc Health District <br /> JI <br /> SS <br /> Business Name (DBA) Address I <br /> i Owner- <br /> -E <br /> Firm Partners, Addresses and T lephone Numbers Emergency Telephone No.W <br /> IL Business Telephone No.• <br /> FLOY' Date <br /> Contractor Licence No. v Title v �. <br /> Applicants Name (Print) 3 f l <br /> 1�7)and Fill in the Required Informa <br /> Please check Applicable Category ( <br /> �. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -- June 30, 19 - ��'-=— - - Disposal Sites <br /> For July 1, - <br /> CAL.License Renewal No. <br /> Description(Make/Yr., Color) <br /> CAL. License No. <br /> Serial No. <br /> Gal.�Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2• ❑ PUMPER YARD <br /> For July 1, Junb 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3• ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> q. ❑ SANITATION PERMIT -' <br /> Job Address/ ocation ) t+i�`�"N1Address <br /> Owner ❑ PACKAGE PLANT <br /> -•❑ SEPTIC TANK 0 CESSPOOL LEACHING FIELD SEEPAGE E lT ❑ OTHER <br /> UXPERMANENT ❑ TEMPORARYr ❑ NEW <br /> 5• 1:1CHEMICAL TOILETS For July 1,-June 30., 19 <br /> _ Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning LOCation(s) <br /> No. of Units <br /> t <br /> 6, PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified r <br /> a �-y <br /> Operator Name N X11Plant Location _ ;a "s'� = No. units Served <br /> Plant Capacity <br /> d <br /> 7, ❑ LAUNDRY For July 1,-June 30,19 ~ <br /> ❑ Less Than 1,000 Sq. Ft.,SIZE: <br /> 4 O',More Than 1,000 Sq.,Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. € <br /> in a <br /> I hereby certify that l have prepared this application and <br /> that the <br /> Joaquin work <br /> Locill beHealdone D strict ccordance with San Joaquin County <br /> ulati s <br /> ordinances, state laws, and.rules a - <br /> APPLICANT'S�SIGNATURE X <br /> riOL a <br /> FOR DEPARTMENT.USE ONLY <br /> ❑ July 1 &Received BY July 31 <br /> Fee IS Due-[] ANNUALLY ❑ PER UNIT REMIT <br /> PER SITE ❑ EACH ❑ January 1 &Received By January CHECKED <br /> BILLING REMITTANCE $ - AMOUNT DUE <br /> d~ DATE --REMITTED - AMOUNT <br /> BASE EXPLANATION DATE u <br /> L .. <br /> FEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> 'PENALTY <br /> OTHER a ,/ ,Aq �•l . <br /> OTHER <br /> # is uance-D a Mailed a Ivered <br /> Receipt No. Permit No. <br /> Received by Date 1601 E.HAZELTON AVE.,F.O.BoK 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL /SERVICES' <br /> APPLICANT <br />