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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ti <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hWKM_1 <br /> on�iusQlless iPSthe jurisdictional area of t ��`yaquin aIth n <br /> FBusiness Name (DBA) _ `� J/Y Address <br /> Owner____ _ __ _ _- Address _. <br /> J Firm Partners, Addresses and Te n Nu ers <br /> CL Business Telephone No. _ Emergency Telephone N0. <br /> Contractor Licence No. <br /> Applicants Name (Print) sl D Title e� -- Date - _ i <br /> Please check Applicable Category (1-7)and Fill in the Required Information On <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 Gel.,Weights 8 Measures No. __._......_ <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD t <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 /> Te. cation Test Date/Time <br /> 4. SANITATION PER T <br /> Job Address! tion <br /> Ow er ��lR AddrAasY_Y1 C ` <br /> .SEPTIC-TANK ❑ CESSPOOL LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT s <br /> `PERMANENT ❑ TEMPORARY NEW ❑ 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) <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-Th'a n 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals U� d/ <br /> eAmount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s and r u t ns of an oaqui cal Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT Cl PER SI TL ❑ SACH ❑ January I $Receiver:By Januar 31a_4t4(y9�)&Rv.rr.,vc,1Byju1y3I <br /> REMIT <br /> BASE EXPLANATION BILLING RFMITIANCE S A UNT DUE CHECKED <br /> j DATF DATE REMITTED AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION , <br /> PLUS - <br /> PENALTY / <br /> OTHER <br /> OTHER <br /> 9rved Dy Date Receipt Nu. ermlt N0. Issuan a Date all Delivered <br /> '.ICANT—RETURN ALL COPIES TO: ENVIRON MENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON.CA 95201 - <br />