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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 WASTE <br /> Applicati i hereby m e to carryon b iness in the ju sdictional area of the an Joaquin o al H thDistric <br /> 33 z <br /> F Business Name(DBA) 5�- Address <br /> ` Address <br /> z Owner <br /> a <br /> J Firm Partners, Addresses and T le hone Numbs <br /> C1. Business Telephone No. <br /> Emergency�TelephIoneNo. <br /> a <br /> Contractor Licence No. Date <br /> Applicants Name (Print) I Title <br /> C Please check Applicable Category (1-7)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 /> f Description(Make/Yr., Color)__ - CAL. License Renewal No. <br /> E Serial No. CAL. L'+cerise No. <br /> Capacity Gal., Weights &Measures.No. <br /> Equipment Parking Address <br /> r 2. ❑ PUMPER YARD <br /> For July 1, June 30. 19 —S <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 4' 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E.Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT14'tucliI <br /> Job Address/L cation S <br /> W <br /> Address <br /> SEPTIC TANK, ESSPOOL LEACHING FIELD _❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 13TEMPORARY 11NEW <br /> 13REPAIR El, OTHER <br /> F 5. ❑ CHEMICAL'TOILETS For July 1, -June 30, 19 r <br /> 1 Type Construction+ Disposal Site I - -- <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, --June 30, 19 Where Certified <br /> Operator Name ' <br /> r Plant Location <br /> II No. Units Served <br /> Plant Capacity <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, Chemicals Used/Amount/Mo. <br /> } I hereby certify that) have prep red this application t the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and and re Ila ti <br /> Joaqu L l H Ith.District. <br /> G APPLICANT'S SIGNATURE X r y _ <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July t &Received EBy July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE Ll <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f^ <br /> OTHER <br /> I <br /> Permit No. ssuan a Date Mailed Delivered <br /> Received by Date Receipt No. _ _' ^��-.T coovrct 1601 E.HAZELTON AVE.,RO.Box 20Q STOCKTON,CA 2Q� <br />