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Applications Will Be Processed When Submlited Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> f� ENVIRONMENTAL HEALTH PERMIT <br /> 1 LIQUID WASTE <br /> Applicatio is hereb r made to carry on business in the jLurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name DBA) �'� e- Address 3 r re- "LL <br /> pP 4 ,�>r,t, Ge (iTddress k <br /> a Owner .�`+�t�,t ut t/r e� � w�'"f <br /> J Firm Partners, Addresses and Telephone Numbers �7 <br /> CL Business Telephone No. 7 7 Emergency Telephone No. <br /> a <br /> Contractor Licence No. S �Y'^A9��V [ <br /> Title Date <br /> Applicants Name (Print) <br /> _ <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. Lic "se 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 />'l 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.O.E. No. e <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> i <br /> Job Address/Location N <br /> i <br /> Owner - w -Ah.ft C — Address <br /> I� SEPTIC TANK ❑ CESSPOOL LEACHING FIELD )6 SEEPAGE PIT 13 PACKAGE PLANT <br /> ❑ PERMANENT 13 TEMPORARY NEW ❑ REPAIR ❑ OTHER ; <br /> 5. ❑ CHEMICAL TOILETS For July 1,--June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i 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 /> i <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 <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 d rules and reguI t' ns of San Joaqu n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> } <br /> FOR DEPARTMENT USE ONLY <br /> .E Fee 15 Due: 11ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH, ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31 _ <br /> - REMIT <br /> BILLING ;r-REMITTANCE $ AMOUNTDUE CHECKED <br /> IBASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> L� <br /> FEE <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 7. <br /> 'r.OTHER <br /> Received by Date Receipt No Permit No. 45suance Date Mailed Delivered <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - tool E.HAZELTON AVE.,P.O.Boxx 2 09�G TOCKKTjON,•CA 45201 �� <br />