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Applications Will Be Processed When Submitted Properly Compieteu. <br /> APPUCATIO4N SEPTAGE <br /> r (For Non-Transterable,Revocable, and Suspendabie) <br /> ENVIRONMENTAL�HEA HEALTH-PERMIT <br /> LIQUID y <br /> ma t car n sine in the jurisdictional area of the San Joh uin Local Ith District <br /> Application' y Address <br /> w Business Nin (DBA) Address - <br /> a Owner <br /> J Firm Partners, Addresses and Telene Nu Viers Emergency Telephone No. <br /> IL <br /> Business Telephone No {vv <br /> Contractor Licence No. -� Title �'. Date <br /> LApplicants Name(Print) E <br /> Please check Applicable Category (�-y) and Fill in the Require Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30;19 - <br /> - Disposal Sites - <br /> Description(Make/Yr.,Color) CAL, License No. CAL. License Renewal No. <br /> Serial No. Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD n, <br /> For July 1, "' June 30. 19 <br /> i • <br /> No.of Vehicles Stored t <br /> No. of Chemical Toilets Stored i <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No- <br /> R.S. or R.C.E. Name Test Date/Time <br /> T eEA400ation <br /> 4,// ANITATION PERMIT �� /�/� <br /> Job Address/Location �g Address 40 <br /> Owner EACHING FIELD R1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL '��"^' ❑ OTHER <br /> ❑ PERMANENT <br /> ❑ TEMPORARY 13 NEW ( REPAIR <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 k <br /> Disposal Site <br /> .Type Construction <br /> No: of Units � � Equipment Storage/Cleaning Location(s) <br /> a <br /> 6, C3 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> -Operator Name <br /> Plant Location No, Units Served ' <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1,-June 30, 19 <br /> Than 1,000 Sq. Ft. - <br /> SIZE: ❑ Less Than 1,000 Sq Ft., - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. i <br /> ppli ion an that a work will a done in accordance with San Joaquin Cou <br /> I hereby certify that l have ty <br /> pare this n <br /> ordinances, state laws, an ul d r ulati soft San aquin Loc alth Distr.ic <br /> r <br /> 'APPLICANT'S SIGNATURE X <br /> '•FOR DEPARTMENT USE ONLY <br /> January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT;,_'��:`❑ PER SITE ❑_EACH _ <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> NATION DATE REMITTED. AMOUNT <br /> BASE EXPLA <br /> DATE- <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY' '"""" - <br /> OTHER Q yn�Jy <br /> OTHER <br /> u e Da MaileDelivered <br /> Receipt No.' Permit No. <br /> 1 d <br /> Received by Date 18D1 E.HAZEL <br /> APPLICANT--RETURN ALL COPIES TO: AVE..P.O.Box 2009 STDCKTON,CA 95204 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />