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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppllcatlon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica Ithereby de to carry the jurisdictional area of the San Joaquin Lo Hea � rict <br /> xkN Business Name (DBA)_ o siness in Address ' <br /> zOwner Address <br /> L) Firm Partners, Addresse4andll phone Numbl —aBusiness Telephone NoEmergency Telephone No. <br /> Contractor Licence NoApplicants Name (PrintTitle Date x <br /> Please check Applicable'Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4 <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 <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.G.E. No. <br /> Test Location Test Date/Time <br /> 4. 1:1 SANITATION PER � �. ` C/ <br /> Job Address/Locati n <br /> Owner w Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGEE ANT <br /> Ifs VMMANENT ❑ TEMPORARY ❑ NEW- ❑ REPAIR R ""SOC r7Ddtl Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 :774_ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 \1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. W <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre ed this application an Tphe work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an and re ulations of oaquin L I He District. <br /> 01 <br /> APPLICANT'S SIGNATUR <br /> R <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - 6 L/' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t7y <br /> 0 <br /> OTHER <br /> OTHER <br /> �(� 5 s � d <br /> Received by Date Receipt No. Permit No- ssua ce Date Mailed <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />