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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 /> i Application hereby madj2LV carry on business th/e''urisdictional area of the San Joaquin oval Health Dist 'c9 <br /> n Business Name (DBA)_ �� � 4)6rAddress �� • � ��r. <br /> aOwner ar! Addresses 4 �� <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 1 S— Emergency Telephone No. \ <br /> Contractor Licence No. 4 <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill In the Required Information n <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19[11; Disposal Sites <br /> +. Description(Make/Yr., Color) 11 <br /> Serial No. III CAL. License No. CAL. License Renewal No. C <br /> Capacity �N Gal., Weights & Measures No. <br /> P Y <br /> CEquipment Parking Address 1. <br /> I 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 if j <br /> R.S. or R.C.E. Name II R.S.or R.C.E. No. <br /> Test Location )� Test Dgte/Time <br /> 4. ❑ SANITATION PERMIT f/ <br /> Job Address/L cation. JCC y J ac- <br /> Owner <br /> C <br /> Owner ` �1 cwe Address 0 6 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT r❑ PACKAGE PLANT <br /> Jf PERMANENT E] TEMPORARY 13NEW gREPAIR W OTHER 5"41"P <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units 11 Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I Where Certified <br /> _Plant Location II <br /> Plant Capacity Il, No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -'ib une 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sg1-Ft., ❑ More.Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals fsed/Amount/Mo. <br /> pgq <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s and regula ions of th San Joaquin Local Health District. <br /> II <br /> ( APPLICANT'S SIGNATURE X dL <br /> f ; I FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY Ii ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> g(f/� <br /> It, <br /> DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS !I <br /> PENALTY <br /> OTHER <br /> OTHER :II. <br /> G <br /> Received by Dale - Receipt No. Permit No. Issuance Date -Mailed eliv ed ,7 <br /> Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- - 1601'E.HAZELTON AVE.,P.O.Box 2009- STOC TON,CA 95201 g <br />