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ter- F Applications WiICBe Processed-When 3ubmilted Properly Completed. Be Sure To Sign The Application. a <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Ap-plicatigriiIis hereby acre to carry o Business in the jurisdictional area of the San Joaqu Lo earth tric <br /> Business Name (DBA) wl3T Address <br /> z Owner Address 7 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 3 .Z Emergency Telephone No. 1 <br /> Contractor Licence No. e <br /> LApplicants Name (Print) Title Date J <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) fl` <br /> For July 1, June 30, 19 Disposal Sites I <br /> Description(Make/Yr-, Color) V a <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER'YARD .�For July 1, June 30, 19 <br /> No. of Vehicles Stored <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 /> - _ - <br /> ._ :Test Date/Time ` _ a �" <br /> Test Location I A <br /> Q. ❑ SANITATION PER T <br /> Job Address ation - <br />.: � - _� - Address <br /> Owner y <br /> ❑ SEPTIC TANK ❑�CESSPO t ACHING FIELD ®'SEEPAGE PIT ❑ PACKAGE PtAANNT� +^ <br /> [ PERMANENT € ❑ TEMPORARY ❑ NEW .REPA113 ..M OTHER H "r• ,� <br /> 5. ❑ CHEMICAL TOILETS-'For July 1, - June 30, 19 #- <br /> Type Construction ' Disposal Site ' } <br /> No. of Units :Equipment.Storage/Cleaning Location(s) • I:y, ¢ <br /> 6.- ❑ PACKAGE TREATMENT PLANT; For July 1—, --June 30, 19 { , <br /> Where Certified <br /> Operator Name -_ Y <br /> Plant Location <br /> Plant Capacity 3 rVo. Units Served s �. <br /> 7. 11LAUNDRY For July.1.,,='June 30, 19 <br /> ClMore Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq.'Ft., r <br /> - ­ f!t <br /> 11DRY_CLFANING, Chemicals Used?..-R mmount/Mo. t ,[ <br /> ADS ; <br /> I hereby certify that I he v aced this applicatio at the.work will be done in accordance w.ith'Sa� 1ojuin County a <br /> ordinances, stag laws, a r"es and gulatio a San J I L' cal Health District. <br /> "i, x y^ } <br /> F <br /> APPLICANT'S SIGNAT - t <br /> T FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑i•.EACH__ -❑.January 1 &Received By January'31 '❑ July 1 8 Received ay'JJIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUN.7 DUE CHECKED ' <br /> DATE DATE REMITTED AMOUNT- <br /> - <br /> FEE <br /> yLESS <br /> Jae <br /> PRORATION <br /> ay <br /> z PLUS r 'F <br /> PENALTY <br /> OTHER <br /> OTHER /ff <br /> ` R_ecei t No. - Issua ce Date -_-..Mailed ehver _.. <br /> Received by w — Dae, P Permit No. <br /> . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 95201 <br />