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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 /> ,r <br /> ApQlicatii �hereby made o carry oobusiness In the'urisdictional area of the San Joaquin Local He Istnct <br /> mBusiness Name (DBA) �' —� Address - - ASF - ��'^� <br /> a Owner - <br /> Address <br /> J.Firm Partners, Addresses and4eoNumbers <br /> 0. Business Telephone No.. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> 1Qj <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) - - <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> k 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 f <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERM1 <br /> 0.3 <br /> `� <br /> Aga 4e <br /> Job Addre /Locati !� <br /> Owner Address ' <br /> SEPTIC TANK ❑ CESSPOOL JKLEACHING FIELD 0,SEEPAGEPIT ❑ PACKAGE PLANT <br /> I .PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> r <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. at Units Equipment Storage/Cleaning Location(s) <br /> M 6. ❑ PACKAGE TREATMENT PLANT for July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> t SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <br /> hereby certify that I.have prepared this appl icatjwrtnthat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a 1 1 and r�egul an Jo q Loca ealth District. <br /> APPLICANT'S SIGNATURE <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fes is Due: ❑ ANNUALLY ❑ PER UNIT Cff PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED r AMOUNT <br /> r �f <br /> FEE <br /> LESS <br /> r PRORATION Y <br /> ![ PLUS <br /> 'PENALTY � <br /> i OTHER " _ <br /> ,OTHER i' <br /> �s7 grz -7 <br /> _ Received by Date Receipt No, PermitLNo- Issuance Date Mailed Delive d <br /> AVE.,P.O.Box 2009 STOC TON <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON ,C 95 <br />