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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 J <br /> LIQUID WASTE <br /> Application is h re de t arty on b sine �jsdlctjonal area of the San Joalm Business Name (DBA) Y A d ess <br /> aOwner dre <br /> J Firm Partners, AddressAandTberaBusiness Telephone Nor Emergency-Telephone No.Contractor Licence No. <br /> L Applicants Name (PrintI Title Date . <br /> Please check Applicable Category 0.7)and Fill in the Required Information <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 x <br /> No. of Chemical Toilets Stored ' <br /> K <br /> 3. ❑ PERCOLATION TEST 4 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No.` i <br /> Test Location Test Date/Time . <br /> 4.--_S(4ANITATION PERMIT <br /> Job Addres /Lo anon <br /> OwnerbC>YLG ievi -t"��f VVI <br /> ''S ll� tim�+nn 4.11 Address <br /> SEPTIC TANK ❑ CESSPOOL �S�EACHING FIELD •0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 19 IEW ❑ REPAIR ❑ OTHER , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site- - <br /> No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 j <br /> Operator Name Where Certified -- J <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7.- ❑ LAUNDRY i 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. a - <br /> t <br /> I hereby certify that I have pr ar this-application a t t th ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d r nd regulations o th Jo i cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 Q July 1 &Received By July 31 <br /> - - - - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED qAMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY F <br /> OTHER- <br /> OTHER <br /> THEROTHER } <br /> ke <br /> Received by t I Date I Receipt No Permit No. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />