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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 /7 <br /> Applicatio is h reby de carry usi ss" the jurisdictional area of the SFV oaqu' Local Health Di trict <br /> 7 Business a (DBA) Addres I r K L <br /> z Owner-7 Ad s �' 1 <br /> Q ! a <br /> 1 <br /> Firm Partners, Addresses and Telephone Numbers � <br /> aBusiness Telephone No. � �. 393.3 Emergency Telephone No. � (1 <br /> Contractor Licence No. I:D� �Cf <br /> X Applicants Name (Print) _ Title t`,Lt3 N F A, Date �:/�-7 <br /> V% <br /> Please check Applicable Category (1-7) and Fill in the Required Information � <br /> r 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For.Juiy 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. ` <br /> Capacity Gal., Weights & Measures No. C <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> ` jNo- 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. C <br /> Test Location Test Date/Time <br /> 4. 'SSANITATION PERMIT <br /> Job Address Location --2,3,5 . <br /> Owner Address <br /> {- Lf SEPTIC TANK ❑ CESSPOOL EACHING FIELD CSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY R 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 /> 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 /> 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, and nd regula " f e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> " FOR DEPARTMENT USE ONLY <br /> ( Fee Is Due: ❑ ANNUALLY .❑ PER UNIT PER SITE ❑ EACH EIJanuary 1 &Received By January 31 - El July 1 &Recekved By July 31 <br /> J - BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATIONAMOUNT DUECHECKED <br /> DATE DATE REMITTED - - <br /> AMOUNT <br /> t <br /> FEE r! J- <br /> r LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 9 <br /> zi <br /> Received by Date Receipt N. �rm No. Issuance Date Mailed Deliver <br /> " APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20091 STO�, ON, 20t <br />