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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of <br /> -the San Joaquin Local Districtt f <br /> OF Business Name (DBA) �/� j" / Address ..�fs3 5- CYjG.+?Dlti� <br /> ~ A/'i�c' '` v� ��,Tc/Y• Add ress / C <br /> zz Owner <br /> U Firm Partners, Addresses and Telephone Numbers <br /> A -_,� p _ Emergency Telephone No. <br /> a Business;Telephone No. <br /> Contractor Licence No. ew <br /> Applicants Name(Print) Title• � � � -Date <br /> Please check Applicable Category,(1-7) and Fill in the Required InformAtion f;: £ :a. u G_ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; '�June 30, 1.9 -�` - � "-Disposal Sites <br /> Description(Make/Yr., Color) n- <br /> Serial No. CAL. License No. CAL. License Renewal No. 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.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner e 4 7- Address� A eg '92X1/7/ <br /> 1:1SEPTiC TANK 11CESSPOOL LEACHING FIELD k��SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW AREPAIR ❑ OTHER ; r _, <br /> 5. ❑ CHEMICAL TOILETS for July 1, -June 30, 19 . os <br /> Type Construction Disposal Site ; <br /> No. of Units Equipment Storage/Gleaning Location(s) ri <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> Where Certified <br /> Operator Name - <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 J "` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ; <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1. <br /> hereby certify that I have prepared this application and that the work one in accordance with San Joaquin County <br /> ordinances, state laws, anru and regulations of the Joaqu' t Dis t. s' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <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 $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION -� DATE #' DATE MITTED AMOUNT <br /> i r <br /> FEE 3 <br /> LESS <br /> PRORATION , <br /> PLUS s 1 1• <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> 1607 E.HAZELTON AVE.,P.O.Bo:2009 570CKTDN,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ' <br />