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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> = APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> � •- LIQUID WASTE <br /> Application is hereby made t arry on business in the jurisdictional area of the n Joaquin Local Health District Z <br /> rn Business Name (DBA);®� - �<SZ� y Address `0' <br /> aOwner _. Address P <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.���' 9� Emergency Telephone No, <br /> Contractor Licence No. :3 <br /> Applicants Name (Print) "4 Title Date <br /> Please check Applicable Category (1-7) and F1II in the Required Informati <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30,19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> f <br /> Capacity' Gal.,Weights &Measures No. <br /> I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <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 /> i Test Location; Test Date/Time <br /> 4�A, SANITATION PERMI ry Z <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 19 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY 11NEW REPAIR13 OTHER R <br /> 5. ❑ CHEMICAL TOILETS For July 1,-'June 30,19 -5 �� g �►' <br /> I" Type Construction F Disposal,Site F'% ` <br /> No. of Units 4 Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 . . <br /> Operator Name Where Certified t - <br /> Plant Location ! M <br /> Plant Capacity R No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 0, 19SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq. Ft. y ' - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I fl <br /> Home ownarorllbaneedRgent'sslgnete�mcer*.H3ecthafnlloW!n "I c:rjifv that:n the pc:rfcrrnanoo of the work fc,which this permit is issued,I stzli not arnpiny any perw <br /> in such mannw EIS to become,SUbort t:;(),'I;IYI.'iS'.".4;> @^S5I'":t'c:".' di •ilii C:'13." r <br /> contreetor's at ee b-a�^tr4 :l,:Ii'aic l Ts`;1;: ;.Jr;i;S.S, :.-? t rir�v�i::�;: I certify iiiat in the perior,•name of the work for which this permit is issued,I shall <br /> jmploy persons Subject to 17odurian's CDMI)ViLfloll iavjs Of La iiCr li4." ' <br /> I hereby certify that I'have prepared this application and that the-work"be done in accordance with San Joaquin County <br /> ordinances, state!aws, a 191-e andre lation f a oaquin L I e District. <br /> APPLICANT'S SIGNATURE X ~ <br /> 4 <br /> FOR DEPARTMENT USE ONLY y <br /> .. � L4r k 1 }'z <br /> Fi?e 1s Due: ❑ ANNUAL v ❑'PER ONIT ❑ PER$IFE'N a❑ EACH ❑ January 1'&Received By-January-31�" ❑wzy.1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $"� �+ s AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Yom... <br /> i <br /> -_1.LESS` ;� y�-'•' � �ati'. _� _ <br /> PRORATION <br /> .;. 4 PLUS Y r z 3 >2. .+ a <br /> PENALTY- fir" `7 <br /> OTHER (, <br /> _OTHER J <br /> _ Received by Date !Receipt No. Pe4" .2—a- - ssuanc Date Mailed D ivered <br /> SAYE.,-P.O.Box 2409 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON STOCK�7ON,CAqS201 <br />