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5 _Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> An y (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> k LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District ; <br /> H Business Name (DBA)_�..�. �A�P' -!s« s � Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a (�_ �o Emergency.Telephone No. <br /> a. Business Telephone No. a <br /> Contractor Licence No. 3 <br /> Applicants Name (Print) F �+D"o Title .E r' ss Dale <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, June 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 /> Ui <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 /> Test Location Test Date/Time <br /> 4. JK SANITATION PERMIT <br /> 4 Job Address/Location e 7-0 C-,4-- ]-d.�i <br /> I ,Owner U -r . 0 0 Address a ISO <br /> g SEPTIC TANK ❑ CESSPOOL Jq LEACHING FIELD JK SEEPAGE PIT ❑ PACKAGE PLANT <br /> NI PERMANENT ❑ TEMPORARY 0 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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> j. 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> j ❑ DRY CLEANING, Chemicals Used/AmounVMO. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> b ordinances, state laws, and rules and regulations of the oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> j 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 /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> ! FEE S <br /> LESS <br /> PRORATION <br /> 1 PLUS ` + <br /> PENALTY �0 w <br /> OTHER <br /> OTHER <br /> k. ^7 <br /> - - 11��r Q <br /> 4' <br /> Received by, Date Receipt,Na—�- - Permit No- Issuan Date Maiked DekiYer d= <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON`AYE.,P.O.Boer 2009 ST_OC TONGA 95�20j1� -� _ <br />