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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> •-yI APPLICATION <br /> }� { (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> l� <br /> LIQUID WASTE <br /> Application is heretW made to carry on b ness in the juAsddiicI <br /> ctional area of the San-Joaquin rLoo�cal Health (strict <br /> N Business Name (DBA)4V A 9�� �—Address `S� WO u- CR' 9 rzol <br /> z Owner Address <br /> e <br /> u Firm Partners, Addresses and Telephone Numbers <br /> CL -Q Emergency Telephone No. <br /> a Business Telephone No. <br /> a �1 <br /> Contractor Licence No. <br /> Date <br /> Applicants Name (Print) Title — S I <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 y <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time _ <br /> 4. K SANITATION PERMIT "3 <br /> Job Addre s/Location F a <br /> Owner Address <br /> SEFdtNK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT W <br /> PERMANENT ❑ TEMPORARY ANEW ❑ REPAIR ❑ OTHER <br /> 5. d CHEMICAL TOILETS For July 1, -June 30, 19 5 <br /> Type Construction Disposal Site f <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 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 accordanceh9an Joaquin County <br /> ordinances, state laws, an rules and r ulatio f the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> tO <br /> FOR DEPARTMENT USE ONLY -' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EAC EpJanu y' ;&T4f=ed By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REM( T $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER ` <br /> OTHER rr <br /> V <br /> Received by Date Receipt Permit 10. issuance Date Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMI AL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Soxr2009 STOC ON,C 5201 <br /> a' <br />