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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br />� <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is her by made to carry On business in the jurisdiction al area of the San Joaquin Local H Ith Distric <br /> FBusiness Name (DBA) �/4• [��� i1lS 4r`, C Address ��3'v 1TK� �G. gSZc <br /> a Owner Address <br /> Firm Partners, Addresses and-Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. y <br /> a <br /> Applicants Name (Print) s Title - ��`�• _ Date �Z d <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - <br /> . I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 i <br /> Serial No. ` CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> i Equipment Parking Address <br /> f 2, ❑ PUMPER YARD " t <br /> For July 1, June.30, 19 1 <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 /> I <br /> Test Loc ion Test Date/Time <br /> i 4. 2SANITATION PERMIT A. <br /> Job Address/location BDgT ��[a �GA�lJ�4 . 1�c^JS-r-AeA,) I� <br /> Ow er / f Address- %� D<SE•� /dPrt�l< 17IA%-R,1t),* O i <br /> R SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ETIPERMANENT ❑ TEMPORARY WN'E VV " ❑ .REPAIR ❑ OTHER �1 <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 /> c 6. ❑ PACKAGE TREATMENce <br /> T PLANT For July 1, -'June 30, 19 N <br /> Operator Namert 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. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that-1 have prepared this ap licatio_9 and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la d rules` regul ns o e n Joaquin Local Health District, <br /> 1 APPLICANT'S SIGNATURE <br /> u 4F .. <br /> s FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑mANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE b DATE REMITTED' <br /> .. AMOUNT - <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> F OTHER <br /> OTHER <br /> Received by - Date - Receipt No. -- Permit No. Issuan a Date Mailed Delivered - - <br /> ' APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT.N.CA 95201 _ <br />