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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 <br /> Application is hereby made to carry on business in the1 urisdictional area of the San_Joaquin Local Health District _ <br /> Business Name(D A)— + GG- Address . �r4je���� � A - <br /> z Owner ' �-� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. �{ ��1 Emergency Telephone No. <br /> Contractor Licence No. .� <br /> Applicants Name (Print) C Title tee./ Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, June 30, 19 Disposal Sites 7-1 <br /> Description(Make/Yr., Color) <br /> CAL. LicenseNo.� CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal., Weights%7IVleasures No -� <br /> Equipment Parking Address -� <br />` 2. ❑ PUMPER YARD <br /> For July 1, - June 30, 19 ~ <br /> No. of Vehicles Stored _ <br /> No. of Chemical7oilets Stored <br /> 3. ❑ PERCOLATION TEST f- <br /> R.S. or R.C.E. Name R.S. or R.C.E'.'No. w y r•, <br /> .r <br /> { <br /> Test Location Test Date/Time <br /> s <br /> 4. ❑ SANITATION PERMIT / C77 <br /> I- Job Address/Location <br /> Address <br /> Owner e'' ` i^, Er- ,,/ .C_ � �r �.q�Y' <br /> I�S7=PTIC TANK ❑ CESSPOOL"" BLEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1:1 PERMANENT 11TEMPORAFIY 11 NEW ❑ REPAIR <br /> 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t ,� <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 —7 <br /> Where Certified <br /> Operator Name <br /> t Plant Location H <br /> Plant Capacity No. Units Served R <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 `- <br /> SIZE: 11 Less Than 1,000 Sq. qtr ❑ More Than 1,OD0.Sq.-Et.� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 � <br /> I hereby certify that I�have prepared,,this application.and that the work will be'done in.accordance with San Joaquin County <br /> ordiliances, state laws;and rules an Tpggul 'ons o t e San Joaquin Local Health District:_ E <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY �= <br /> art <br /> y <br /> Fee Is Due: ❑ ANNUALLY ❑.PER UNIT El PER SITE EI EAC ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ 7 REMIT <br /> B{LLING REMITTANCv' $ -AMOUNT DUE. CHECKED . <br /> BASE EXPLANATION DATE DAT REMITTfO AMOUNT <br /> E <br /> FEE 5 . <br /> LESS i r <br /> PRORATION - <br /> 1 . <br /> PLUS } 30 ' <br /> I PENALTY <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deliv�/�_APPLICANT—RETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601`E.HAZELTON AVE.,P.O.Box 2009- STOC , , <br />