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Applications Will Bep 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 /> f� Q LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />{ y Business Name (DBA) V 5I1r Z c. Address 12 <br /> z OwnerAddress <br /> a <br /> U Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 39-7 1 Emergency Telephone No. <br /> 6 Contractor Licence No. <br /> LApplicants Name (Print) f_.[� WOOD Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information O� <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 Rencwal 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 y �. <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. a SANITATION PERMIT <br /> Job Address/Location 2-2- <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> X PERMANENT ❑ TEMPORARY `',•'� NEW ❑ REPAIR ❑ OTHER <br /> y 5. ❑ CHEMICAL TOILETS For July 1, -June 30,-,19 <br /> Ikkk Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> 1 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I� Plant Location <br /> r 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 accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 4. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 -oved By January 31 . 0 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES <br /> LESS <br /> PRORATION <br /> I PLUS <br /> j PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date- Receipt No. Permit No.. Issuance DaRe Mailed elivere <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„,P.O.ao,2009 STOCK N,CA N2 1 <br />