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Applications Will Be Processed When Submitled 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 /> Appl ication i ereoy rade t carry on bus' ess in th/juris tionaI area of the S Joaq Local Health District <br /> rBusiness Name (DBA- "� Address �� <br /> r <br /> z Owner_� �� Address <br /> a Owner <br /> Firm Partners, Addresses and Telephone Numbers <br /> EL Business Telephone No, ©� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Titie , Date <br /> Please check Applicable Category (1-7) and Fill in the Required 1 formation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> �• ?++ .,. -t. <br /> For July 1, June 30, 19Disposal Sites <br /> Description..(Make/Y_r., Color) . 4 ' <br /> Serial No:— – CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity's �'GaI Weights & Measures No. j <br /> -* 1-Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> Fo�'Julyrlt--- 7�"June. 30, 19 ` <br /> No. ofVehicles.Stored' <br /> i No. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST ' <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. V <br /> i Test Location Test Date/Time ' <br /> k 4. ❑ SANITATION PERMIT <br /> lid <br /> Job Addr s/vocation <br /> Owner ' d- d''-rc � � '"i1 Address 1- <br /> 9l PTIC TAN ❑ CESSPOOL x�EACHING FIELD IT ❑ PACKAGE PLANT <br /> ®/PERMANENT ❑ TEMPORARY �( N ❑ REPAIR ❑ OTHER ' Nt <br />` 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I 'd, I y <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) e <br /> '6. 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �t� i�y�, i <br /> � <br /> Operator Name ' 'Where 4Certified. <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity ) <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. fM <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. =' t 7 <br /> Ear ! <br /> IN. ' <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 rul nd regulatio a an 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 /> R BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Lam/ �cf <br /> 3 <br /> LESS— �- <br /> PRORATION <br /> PLUS <br /> PENALTY r ! gL <br /> OTHER <br /> t ,__, _ . <br /> !F OTHnER <br /> 0 b 3 (p r-7 <br /> Received by DateReceipt No - Permit No. Is uance Date Mailed Delivere <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCK N;CA 9 01 <br />