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.� Applications Will Be Processed When Submitted Properly Completed. Be Sure <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE + <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) AS tc! cm�57tI -11�� Address�y-� � <br /> z Owner Address <br /> a r <br /> J <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. a <br /> a <br /> 1 <br /> Contractor Licence No. <br /> d2fA;'5p <br /> Applicants Name (Print) 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, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No, <br /> Serial No. CAL. License No. <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 R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> i Test Date/Time <br /> Test Location <br /> 4. X SANITATION PERMIT <br /> Job Address/Location7� a ' '� <br /> .. � Address <br /> Owner 11 PACKAGE PLANT <br /> 1 11 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Ill SEE AGE PIT 11 OTHER <br /> 1 14 PERMANENT 11 TEMPORARY 11NEW 0 REPAIR <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 Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 11LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance ith S oaquin County. <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> k APPLICANT'S SIGNATURE X q <br /> FOR DEPARTMENT USE ONLY al <br /> Fee Is'Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By Janu ry ❑ July 1 &Received ByJuly <br /> 31 <br /> REMIT <br /> 4. BILLING REMITTANCE AMOUNT DUE - _CHECKED <br /> 4 BASE EXPLANATION DATE DATE REM TTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> F <br /> ' - Date Receipt No. Permit No. Issu nce ate Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO:,, -ENVIRONMENTAL HEALTH PERMJT/Si=RVICES - 1601 E.HAZEk,TON A . .'_'lBox 2009 STOGKTON,CA 95201 <br />