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TObign i"r <br /> ' Applications Will Be Processed When Submitted Properly Completed. BeSure <br /> APPLICATION <br /> (Far Non-Transferable, Re'ocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAIJ!HEALTH PERMIT <br /> LIQUID WASTE- <br /> I <br /> ess in the jurisdictional area of the San Joaquin Local Health District <br /> Application is hereby made to carry on busin <br /> Address <br /> m Business Name {DBA} d <br /> Address <br /> aOwner Ij <br /> ,Firm Partners, Addresses and Telephone Numbers Ill. Emergency Telephone No. <br /> C6 Business Telephone No. — II <br /> Contractor Licence No. 308171 Title OXTnrar Date �I <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill In the Required Informatlon <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 /> '- <br /> Gal.,Weights &Measures Na <br /> Capacity . <br /> li <br /> Equipment Parking Address til <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> . No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> 3_ ❑ PERCOLATION TEST `s. <br /> R.S.or R.C.E.No. <br /> p R.S. or R.C.E. Name Test Date/Time101 <br /> (b <br /> } Test Location �. v 43 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location Add res, <br /> Ij <br /> Owner ❑. PACKAGE PLANT <br /> ZSEPTIC TANK ❑ C §SPOOL �EACHINGFIELD SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July i', -June 30, 1Disposal Site ' <br /> Type Construction <br /> M Equipment Storage/Gleaning Location(s) <br /> No. of Units <br /> l g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 I Where Certified <br /> Operator Name I� <br /> Plant Location No.units Served <br /> Plant Capacity ~ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 rules and regulation he SanJoaquin L cal' Ith District. <br /> F. APPLICANT'S SIGNATURE X <br /> t i - <br /> FOR DEPARTMENT USE ONLY <br /> IN <br /> 31 <br /> _ REMIT <br /> fee.IS DUB: ❑ ANNUALLY ❑ PER UNIT la PER SITE ❑ EACH � January 1 Received By January 31 July 1 8 Received 6y July <br /> t <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASF EXPLANATION DATE l DATE REMITTED AMOUNT <br /> F FEE <br /> LESS El <br /> PRORATION - <br /> PLUS q <br /> f PENALTY <br /> OTHER �' r <br /> c3 OTHER <br /> 7y <br /> ?� Issuance Date Mailed Deli red <br /> Date - Receipt No. - Permit No A 952 <br /> received by +. - ,...v a 4 V .O.aox 2049 S TO <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERfNITISERYICES E HAZELTON ' <br /> 76 5 A £. P T K <br />