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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �m <br /> APPLICATION <br /> S�, z� i ' <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is y de to c A2r, rfiess'n the jurisdictional area of the S Joaquin LpGa4,Health tr t � <br /> U) Business Na BA) ` 1 Addresses <br /> a Owner d,. Addressjr <br /> . i <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. '- Emergency Telephone,No. <br /> Contractor Licence No. r <br /> Applicants Name (Print) t- Title f .Date - .--- <br /> 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, Jurie 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 t <br /> No. of Vehicles Stored <br /> .No. of Chemical Toilets Stored <br /> 3. t] 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��SANITATION PE MIT Ct s o� <br /> Job Address/ c , �` ' I <br /> Owner Address# w <br /> EPTIC TANK CESSPOOL /i't'EACHING FIELD EPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY �=NEW ❑ REPAIR ❑ OTHER a <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 " { <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleahing Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19. <br /> Operator Name I Where Certified = <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t LL 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. 41—ze- <br /> 2` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepa ed is ap ati- an that work wi be done in accordance with'San Joaquin County <br /> ordinances, state laws, and rul dreg n f thean uin L Health Districx ._ . <br /> APPLICANT'S SIGNATURE X < `� ' <br /> FOR DEPARTMENT USE ONLY 77`f—J <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 $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> �1 <br /> DATE . ,DATE REMITTED AMOUNT <br /> FEE L <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER Ar '97 <br /> OTHER t ' <br /> 4- <br /> Received by Date 'Receipt No. Permit No. Issuhneb Date Mailed Delivered' . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />