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Applications Will Be Prn sed When Submitted Properly Completed.Be Su Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable;and Suspendable)_. SEPTAGE <br /> ENVIRONMENTAL HEALTH•PERMIT <br /> LIQUID WASTE <br /> Application iarryonposIness In the rlsdictional area of the�9jn,)oa i t FJeallistrict <br /> h Business Name (DBA)_ ��,Address (i, <br /> Owner Address— - <br /> Firm Partners,Addresses and Telepho ie Numbers :.. <br /> a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) Title. Date i <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE) �V <br /> For July 1,-- • June 30, 19 DISP0581 Sites- - <br /> Description(Make/Yr.,Color) ..- k ' <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 /> Te ocation Test Date/Time <br /> 4, SANITATION PERMIT <br /> Job Address/ oc tion <br /> Owner 'V - HL LA S A Address r <br /> ❑ SEPTIC TANK ❑ CESSP_OOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT p �Q <br /> ❑ PERMANENT' ❑ TEMPORARY - ❑ NEW C�REPAIR OTHER QfXy4! JFE.P o(I <br /> S. ❑ CHEMICAL TOILETS For July 1,•June 30, 19 <br /> i <br /> Type Construction I Disposal Site < 4 <br /> No.of Units ' ' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE,TREATMENT.PLANT , For July 1, -June<l0,`19 <br /> Operator Name <br /> i - I 1 �. - Where Certified � ) <br /> Plant Location <br /> Plant Capacity - I No Units Served 1 ,;�► t t <br /> 7. ❑ LAUNDRY' For July 1, =June 30, 19 r _. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1',000 Sq, Ft. <br /> ❑ DRY CLEANING,Chemicals Used/AmountRv16. <br /> 91,+, <br /> I f hereby,certII that,l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> brdinl ri'c6s;s'd IaJvs, and rule d regulation 0f the S q"Lcealth District. <br /> APPLICANT'S SIGNATURE Xi!.- <br /> FOR DEPARTMENT USE ONLY' <br /> Fee Is Due: ❑ ANNUALLY ❑ PFR UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION .s DATE -DATE .REMITTED AMOUNT DUE CHECKED <br /> • � 's AMOUNT � <br /> FEE 1\4 I- 1 ��'i "o f. :✓� <br /> LESS , <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Recelved by Date Receipt No. Permit No. Issuan a ateail Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PFAWNSERVICES 1601 E.HAZEL70N AVE.,P.O. ox 2009 •STOCKTON,CA 95201 <br />