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Appllcations WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Appilcation. <br /> a APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ma t�o car on basin ss in the ris ictional area of the San oa uin Lal H Ith.Di trict <br /> Business ame (DBA) Addres x1 <br /> a Owner Addres " Ire <br /> u Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No �$7 � _ Emergency Telephone No. _�It <br /> Contractor Licence No. _ /�� _ 1"V <br /> Applicants Name {Print) Title.�oR,[,��''t �� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information � j <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t V_ <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 /> f <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.G.E- Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time _ <br /> 4. ❑ SANITATION PERMIT`�� J <br /> Job Addrreesss/Localion�,-`7_! C,) <br /> X,j,, er ? _�T5 ..-_ _.__ Address <br /> EPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT- <br /> PERMANENT ❑ TEMPORARY ANEW, ❑ REPAIR ❑ OTHER <br /> 5. 0 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 __S) <br /> Operator Name — Where Certified <br /> Plant Location _._-.__.._._.__._. .. .. <br /> Plant Capacity f _.__ 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. , e <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that l have prepared this application and that the work a don in accordance with San Joaqu ounty <br /> ordinances, state laws, an rul 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 ❑ EAGII ❑ January 1&Received By January 31 ❑ Ju'y 1 &Rec:ewed ny July 3l <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DU HFCKED <br /> DATE ' DATE �REMITTED� LINT <br /> 44 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS /01 <br /> PENALTY - - ._ <br /> 17 <br /> OTHER <br /> OTHER <br /> Received by ate. L Pennd No. Issuance ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ----- <br />