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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppucanon. <br /> :i APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> .i <br /> Application is reby made to arty on busi ess in the j isdi ional area of the 5 Joaqu' Local Health District <br /> OF Business Na DBA) Address <br /> z Owner Address ��"–�- - t <br /> J Firm Partners, Addresses and Telephone Num ers 4 <br /> IL Business Telephone No. � n Emergency Telephone No. <br /> f 4 zL <br /> Contractor Licence No. <br /> LANRlicants Name(Print) Title Date �� N <br /> Please check Applicable Caiegory (1-7)and Fill in the Required Information J 'j <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 l Disposal Sites 2: <br /> Description(Make/Yr., Color) <br /> Serial No". A # "'' CAL. License No. CAL. License Renewal No. 4V' <br /> JA <br /> Y <br /> Ca acit Gal.;'Weights & Measures No. <br /> Capacity .�.. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 1 "� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored II <br /> 4 3. ❑ PERCOLATION TEST <br /> i R.S. or R.C.E. Name +« R.S. or R.C.E. No. <br /> TeskSAINITATION <br /> tion <br /> 9Test Date/Time <br /> 4. PERMIT <br /> t 7/ <br /> Job Address/Location �7 <br /> Owner @ �� Address <br /> 13SEPTIC TANK 13CESSPOOL L-LEACHI.N.G-FIELR=E):SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY i ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1;-June 30, 19 <br /> Type Construction II Disposal,Site _ <br /> No. of Units Equipment Storage/Cleaning Location{s) <br /> At 44 <br /> 6. 1:1 PACKAGE TREATMENT PLANT L For July 1, -June 30, 19 ¢r <br /> Operator Name <br /> " f Where Certified <br /> Plant Location - <br /> Plant Capacity No, Uriits Served " <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 111 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, t <br /> i <br /> I <br /> I <br /> I hereby certify that I have prepared this applicatiorrand that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s and regulation of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I� FOR DEPARTMENT USE ONLY <br /> I <br /> Fee IS Due: ❑ ANNUALLY C3 PER UNIT PER SITE EACH 1:3 January 1 $Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> j BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> i <br /> ks - � <br /> FEE a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> p Received by Date i� Receipt No. -Permit No Issua ce Date Mailed IDeliAPPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1Sol E:HAZELTON AVE.,P.O.Box 2009N,'CA 9'� <br />