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Completed- se sure 10 a+yr, <br /> Applications Will Be Processed When Submitted Properly Comp <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTEIt <br /> t <br /> 7 � <br /> Applicati n hereby ade t carry on business in the jurisdictional)area of th + JO pin Local He�ith s nc <br /> Business Name.(DBA) Address <br /> aOwner ',p <br /> J Firm Partners.,,Addresses and Telephone Numbers Emergency Telephone No. <br /> 0. Business Telephone No. 3 2 7 I ! <br /> 1 Contractor Licence No. _ Title Date <br /> Applicants Name (Print) _ <br /> Please check Applicable Category (1-T) and fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �= <br />� June 30, 19 Disposal Sites <br /> For July 1, Y <br /> Description-(Make/Yr:, Color) CAL. License Renewal No. <br /> CAL. License No. a <br /> Serial No. LL <br /> Gal.,Weights & Measures No. <br /> Capacity ' <br /> 1 Equipment Parking Address <br /> 2, ❑ PUMPER YARD �y <br /> For July 1, June 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 Test Date/Time <br /> Test,Location <br /> 4. LT SANITATION PERMIT N <br /> Job Addres /Location w Address <br /> O,,wn� E LEACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT <br /> vt <br /> LH SEPTIC TANK 11 CES" <br /> NEW ❑ OAR 2 �� <br /> O REPAIR <br /> ❑ PERMANENT ❑ TEMPORARY f� s`�Gp�y <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 4 <br /> Disposal Site <br /> Type Construction +� <br /> No. of Units Equipment Storage/Cleaning Location($) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> t <br /> Operator Name <br /> Plant Location No. Units Served <br /> i- <br /> Plant Capacity <br /> T, ❑ 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 /> € lication nd th the work will be done in accordance with San Joaquin County <br /> l I.hereby certify that I have p d this app -octal Health District. <br /> ordinances, state laws, an rules d regulation o t San ti <br /> E <br /> APPLICANT'S SIGNATURE X <br /> j FOR DEPARTMENT USE ONLY <br /> l _ ❑ PER SITE ❑ EACH - ❑ January i &Received By January 31 ❑ Suly 1 &Received REMIT <br /> uly 31 <br /> PER UNIT <br /> f <br /> Fee Is Due: ❑ ANNUALLY REMITTANCE $ AMOUNT DUE CHECKED <br /> BILLING REMITTED AMOUNT <br /> F BASE EXPLANATION PATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHEROTHLR <br /> r f <br /> 44 �" 47 <br /> / L -Z i Mailed Delivered <br /> "T` Received by�s-' ��, .. � E:'HAZELTON AVE.,P.O.BOY 2009, STOCKTON, <br /> rt <br /> ��,�.pppLICANT-RETURN AL4.COPIEST9:r.Y ENVIRONMENTAIHEArtTHPERMITISERVIC E � �-� _ - <br />