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APPLICATION <br /> )r Non-Transferable,Revocable, and Suspendat SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 'r <br /> LIQUID WASTE <br /> Application is hereby ma to car on busin ss in the ris ictional area of the San oa uin L cal H Ith Di trict <br /> yBusiness ame (DBA) Addres <br /> aOwner l - _ Address <br /> Firm Partners, Addresses and Telephone Numbers. <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Nan qonn C10.,j Title OA, XI Lr_—— Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information Uj <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 11 SANITATION PERMIT <br /> Job Address/Locafignq��, <br /> O er 45 Address <br /> SEPTIC TANK CESSPOOL LEACHING FIELD, ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> XX, <br /> PERMANENT ❑ TEMPORARY ANEW- ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19,z4_' <br /> Type Construction - Disposal Site 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) 4 <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. <br /> ❑ DRY CLEANING, Chemicalls-Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work a don in accordance with San Joaqu' ounty <br /> ordinances,state laws, an rule and regulations f the San Joaquin L al Health Dist 'ct. <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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DU NECKED <br /> l OU <br /> FEE 1 y t O <br /> LESS 1 R <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6 1 /6-7 <br /> Received by Date 1. Frecellpl­4q& Permit No. Issuance D ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A E.,P.O.Box 2009 STOCKTON,CA 95201 <br />