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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppllication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i h eby 1111,11 e to arry n business in he jurisdict nal area of the Joaquin oval Hea Di t <br /> F Business Name {DBA) sem` � ` <br /> �- _kAddress ��p �r b!V v C4 <br /> z Owner <br /> Address <br /> 4 <br /> LFirm Partners, Addresses and Tele hone Numbers <br /> aBusiness Telephone No, S� Emergency Telephone No. <br /> Contractor Licence No. S� <br /> Title Date <br /> �Applicants Name (Print) <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 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. U <br /> Capacity - Gal., Weights & Measures No. <br /> f' -S <br /> i <br /> Equipment Park ngYAddress_ <br /> 2.113 PUMPER YARD <br /> ForJuly 1,' " June`30,`7y <br /> No. of Vehicles,Stored <br /> No. of Chemical Toilets Stored- <br /> 3. 13PERCOLATtON`TE$T <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PEA <br /> irr ffp 110L,) <br /> Job Address/Location <br /> Owner Address <br /> SEPTIC TANK 11CESSPOOL LEACHING FIELD 11 SEEPAGE PIT 13 PACKAGE PLANT <br /> 11 PERMANENTS s�"❑�TEMPOR.AR ❑ NEW ❑ REPAIR ❑ OTHER <br /> F ALt-OILETS For July 1 June 30, 19 <br /> 5. El CHEMIC <br /> Disposal Site <br /> �ype-Gonstr+lction p <br /> Na ^" ts �► "' , Equipment Storage/Cleaning Location(s)Uni <br /> �, „R <br /> 6. <br /> PACKAGE TREATMENT PLANT For July 1, - June 30, 19 4-- <br /> ...+ <br /> k E <br /> Operator ... awpool Where Certified <br /> Name r P <br /> Plant Location"""""~"^ . "'F <br /> .�;-P-- r".0w r." - No. Units.Served <br /> Plant Capacity �,, � ,.,, <br />!E <br /> 7711 LAUNDRYwFor July 1,June 30, 19 <br /> SIZE: El Less Than 1,000 Sq. Ft., C3More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t7,1�rer6by,.certify that I have prepared this application and that the work will's a done in accordance with.San Joaquin County <br /> inIs <br /> ordinances, state laws, and rul sand regulation of the San oa uin Lo al'Health District. <br /> APPLICANT'S SIGNATURE X ,..� <br /> FORaDEPARTMENT USE ONLY <br /> Fee' Is Due: ❑_ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juky 1 8 ReceiveR�EMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> - FEE <br /> LESS <br /> PRORATIO j - <br /> PLUS / ! <br /> PENALTY <br /> OTHE <br /> OTHER ' <br /> 1, 1 0 c7 0 yg �U <br /> k Received by D to Receipt No. Permit Issuance Date filed - Delivered <br /> rAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -1601 E.HA2ELTON AVE., x 2009 STOGKTON,CAS <br /> I <br />