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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Ado APPLICATION <br /> s (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicationi�s hereby made to carry on business in the jurisdiction� a San Joa n Local He th District <br /> N Business Name (DBA) io , ��1s �otis� A+ ress <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) �T���- 8 ��'�1S Title G �� - Date —/7—,F(4) <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 T, 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 /> • <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> 4 <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. Name R.S.or R.C.E. No. <br /> Test�LOC tion Test Date/Time <br /> 4. IS SANITATION PERMIT <br /> Job Address/Location Z d-0 AA SG :S7 91 <br /> N <br /> Owner�W---'eS Address 156 <br /> ❑ SEPTIC TANK ❑ CESSPOOL B`CEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW 2-REPAIR ❑ OTHER h <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Coristruction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: Q Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I hayprepared tis application and 14at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, les andgulation5 the Joaquin Local Health District. <br /> /fyfr <br /> APPLICANT'S SIGNATURE <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> '00001- <br /> Received by Date Receipt No Permit No. lssPgnce D to Mailed elive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 95201 <br />