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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign Ines,ppmot-11• V <br /> APPLICATION -� <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE ; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ade to carry on business in the jurisdictional area of the San Joaquin Local Health Dis rlct <br /> ,F Business Name (DBA) D � T 0O 47 <br /> S c tl l E c� Address c,� $. <br /> I.- <br /> Owner <br /> ��C Address 7p S <br /> fJ Firm Partners, Addresses and Telephone Numbers <br /> 4 Business Telephone No. y� Emergency Telephone No. <br /> Contractor Licence No. 3 $� <br /> Applicants Name (Print) <br /> Title 'EST Date <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. 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. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. JZ SANITATION PERMIT <br /> Job Address/Location <br /> Owner w �' //'47/V5z_/-/ Address ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD g SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR S ❑ 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 /> 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. 4 <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 ules and regulations of a 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 ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REM4TTED AMOUNT <br /> r' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. —Permit No. , Issuance Date Mailed Deliy ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH P IT/SERVICES 1601.E.HAYELTON AVE.,P.O.Box 2009 STO KTON, 55201 <br />