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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 WA TFO <br /> Application is ereby made to carry on busi e s th urs 'c I �n Joa n Locealth District f'+ <br /> y Business Name (DBA) Addres I <br /> �1 <br /> z Owner 1.: Address f <br /> a <br /> Firm Partners, Addresses and eiephone Numbers ' <br /> E Business Telephone No. h A. Emergency Telephone No. <br /> I <br /> Contractor Licence No. .r. ._ ` <br /> Applicants Name (Print) Title- Date"11 `Y <br /> Please check Applicable Category (1- and Fill in the Required Information „y <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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST i m <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SANITATION PER1UW�" <br /> Job Address/Location K\-9j Wjr <br /> Oer Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT jr . <br /> 11PERMANENT 13TEMPORARY 13NEW 13REPAIR -` ❑ OTHER (D0O � •1b1 <br /> 5. 13 CHEMICAL TOILETS For July 1, -June 30, 19 �O� ]� <br /> Type Construction Disposal Site r <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. [t <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ! 1 <br /> I hereby certify that I ave re red this application and h t the wor ill be done in accordance with San Joaquin County <br /> ordinances, state law a ul and regulations of theoaquin I Health Di rict. {� <br /> 1 <br /> APPLICANT'S SIGNATURE X ply <br /> o <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 - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER w <br /> OTHER - <br /> -71 <br /> Received by Date Receipt No. Permit No Issuance ate Mailed Delivered <br /> + APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />