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Applications Will Be ProcessecrWhen Submitted Properly Completed. I <br /> APPLICATION <br /> 4 (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL W STE TH PERMIT <br /> LIQUID <br /> 1 <br /> Application is h reby made to carry on business in the jurisdictional areaAddrosthe�8Joaquin Local Health District <br /> � <br /> an l <br /> F Business Name (DBA) Address 1 <br /> c Owner <br /> W <br /> 2 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. f t <br /> o t <br /> It No- <br /> 4 Business Telephone No. <br /> Contractor Licence No. J Title <br /> �� Date �. <br /> L Applicants Name (Print) 1 and Fill in the Required Information <br /> Please check Applicable Category ( ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FODisR o EACH <br /> al Sites <br /> VEHICLE) <br /> For July 1, June 30, 19 _s <br /> Description(Make/Yr., Color).___ _ CAL. License Renewal Ii <br /> CAL. License No. j <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity 3 <br /> I <br /> Equipment Parking Address ` <br />` 2. ❑ PUMPER YARD <br /> t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> 1 <br /> R.S. or R.C.E. Name Test Date/Time � <br /> Test Location f i <br /> 4. ❑ SANITATION PERMIT Fj �- TQ 6� <br /> Job Address/Location <br /> Address ❑ PACKAGE PLANTk <br /> Own r LEACHING FIELD ❑ SEEPAGE PIT Leo <br /> SEPTIC TANK ❑ CESSPOOL El OTHER <br /> ❑ TEMPORARY ❑ NEW RE IR <br /> ❑ PERMANENT } <br /> 5, ❑ CHEMICAL TOILETS For July i, -June 30, 19- <br /> Disposal <br /> 0, 1Disposal Site <br /> Type Construction, j <br /> . E quipment Storage/Cleaning Location(s) <br /> i <br /> a No. of Units j <br /> 1! g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 3D, 19 Where Certified f <br /> I <br /> Operator Name <br /> Plant Location No. Units Served <br /> } Plant Capacity ' e <br /> 7• ❑ LAUNDRY 'For July 1, -June 30, 19 <br /> SIZE: , ❑ Less Than 1,000-'Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY,CLEANING,,Chemicals Used/AmountlMo. <br /> �J -and that the work <br /> r�" <br /> , I'hereby certify that i <br /> ha, rules and re Is lappnsaot the San Joaquin L cal IHea th District <br /> ll be done in accordance with San Joaquin County <br /> ordinances,state laws, an <br /> APPLICANT'S SIGNATURE.x <br /> Y. r <br /> FOR DEPARTMENT USE ONLY <br /> _ Jul 1 &Received By July 31 <br /> PER UNIT PER SITE EACH ❑.January'1-&Received By January 31 y REMIT <br /> Fee Is Due-�❑.ANNUALLY� REMITTANCE $ AMOUNT DUE CHECKED <br /> BILLING RE ITTED AMOUNT <br /> B,SE EXPLANATION DATE DATE_ <br /> � s <br /> FEE ' t <br /> LESS " .. x•' <br /> PRORATION' _- <br /> PLUS <br /> "PENALTY <br /> OTHER <br /> OTHER — - <br /> Receipt No. ermit No. <br /> Issuance Date Mailed Oe d <br /> - Date 1605 E.HAZELTON AVE.,P.D.Box 2409 STOC TON,CA 9 41 <br /> Received by <br /> APPLI6ANT—RETURN ALL COPIES TD: ENVIRONMENTAL HEALTH PERMITISERVICES - <br />