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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Slgr�Application. <br /> APPLICATION st <br /> (For Non-Transferable,Revocable,and Suspend SEPTAGE <br /> ENVIRONMENTAL HEALTH PEq� <br /> LIQUID WASTE ) <br /> Applicatio is her by a to carry on b�jines in tJ�e jurisdictional area of the'. �a �a u,in�'°cal Health Pistrictt <br /> F Business Nam�j(DB�A) �st�_QLT Address �-` ;to gY— �d,...i. <br /> aOwner_ Gc�crC v r Address „l 4AA <br /> Firm Partners, Addresses and T leohone Numbers 741f ;L 3// <br /> r'.35 a Business Telephone No. j3 Emergency Telephone No.S4161, <br /> Contractor Licence No. `7 j <br /> Applicants Name (Print) Ff�C Title �W�'a+ Date 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 r <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 /> ❑ SANITATION PERMIT <br /> Job Addressd/Location Y/ P <br /> Owner C -/7 ��if1i0 Address 51117- <br /> 11 SEPTIC TANK ❑ CESSPOOL Q'CrACHING FIELD ELSEEPAGE PIT 11 PACKAGE PLANT �' y <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ELR'EPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 W <br /> Type Construction Disposal Site r./1 <br /> A <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 T <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/Amourl <br /> I hereby certify that I have pre ared this applica' and t at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a and r ulations f,#A S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> RASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Pen.it No3_84q. ssuen ate Mailetl Deliveretl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Pox 2509 SaVCCF?ON,CA 95 1 _ - <br />