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F Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION <br /> - (For Non-Transferable, Revocable, and Suspendabie) SEPTAGE a / <br /> ENVIRONMENTAL HEALTH <br /> TH PERMITLI <br /> Application is hereby made to ca ry on b s' ss in t �' risdictional area of the San Ja On ocal J�ealth District <br /> yBusiness Name(DBA} — L ` - Address `- - <br /> z Owner Address;Y� �� <br /> J Firm Partners, Addresses an(LTjWe;hone Number <br /> d Emergency Telephone No._ <br /> 0. Business Telephone No. _ H <br /> Contractor Licence No. t` � <br /> r <br /> a Title <br /> Applicants Name (Print) . <br /> Please check Applicatiie Category (1-7)and Fill in the Required In <br /> y, _L ❑;PUMPER VEHICLE-PEHMIT REGISTRATION (FOR EACH VEHICLE) <br /> rft For July 1," p; � June,30, 19 -.-D i sposal.Sites - <br /> Description(Make/Yr., Color) ,r <br /> Serial No. <br /> CAL. License No. I 1 � � � CAL. License Renewal No <br /> Capacity Gal.,,-Weights•&-Measures.No.- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> t No. of Vehiclest'ored` �. c.. <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 Date/Time <br /> Test Location { <br /> 4. ❑ SANITATION PERMIT <br /> Job Ad `ess/Locatio <br /> Owner ? Address 4 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT i I <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWRE�'AIRR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS R.5r July 1,-June 30, 19 _ 1 <br /> l; <br /> Type Construction Disposal Site -, <br /> i No. of Units Equipment Storage/Cleaning Locafionf$) <br /> 6. 11 PACKAGE TREATMENT�PLANT+rFor July 1 =June - — <br /> E` Where Certified <br /> Operator Name L. <br /> Plant Location <br /> 1 Ll:!} P. <br /> Plant Capacity = - - --s No. Units Served <br /> t <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 . <br /> SIZE: `❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000iSq. Ft. <br /> '❑ DRY CLEANING, Chemicals Used/Amount/Mo t , <br /> '„•1C.i:-.�.:..._,u ;,17t;lispnr;ritisissu:,�,9stall not emj1hell <br /> F <br /> €}tome owner rrlicensec,egent',q Signa um--ti�e "'I t <br /> =117 SUCK n1lfiSi+;f 3's t?t1CCOs?1F.5U pit vC K ;: - u )e��- y ' f- ; F•� _ „s -ik,,,;...�r G�the wolk for which this permit is iss <br /> ;Contractors hiring or <br /> employ persons subject to workman's col;lpensatron laws 31 Lc.tl.�•,,.� ; <br /> I h reby certify tha repared this appl'""tion and-that a work will be done in accordance with San Joaquin County <br /> ordina tate laws, nd rule d regu atio S, f th San Jo uin L al He District. <br /> t <br /> APPLICANT'S SIGNATURE <br /> � _. <br /> r 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 /> F BILLING" REMITTANCE $ AMOUNT DUE CHECKED <br /> 4 BASE EXPLANATION DATE— DATE REMITTED - AMOUNT <br /> FEE <br /> Y <br /> LESS <br /> PRORATION - - - <br /> PLUS <br /> PENALTY •'� - - - <br /> OTHER k .4- <br /> � k , <br /> OTHERji <br /> Received by r Dat Receipt No .- Permil No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009STOCK70N,CA 85201 <br /> APPLTCANT—RETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES i • <br /> i <br />