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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �f APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application islier y made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) rdL4c;fL.+ r Address <br /> ..4 _ <br /> a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> r' a Business Telephone No.. Emergency Telephone No._ 4 , <br /> Contractor Licence No. ) <br /> L ;.• <br /> Applicants Name (Print) � Title, Date _ _ - <br /> Please check Applicable Category(1-7) and Fill ln.the Requlred-information <br />�l <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1; June-30, 19 -- " Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. _I CAL..License No., CAL. License Renewal No. <br /> -Capacity 4Galt;Weights 8 Measures No. <br /> Equipment Parking Address ' } �� �•-:. .gyp •-- � <br /> 2. ❑ PUMPER YARD _ <br /> For July 1, = June 30;"1.9 Z �L�� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored v ; <br /> 3. ❑ PERCOLATION TEST , - r " • 3 �. <br /> R.S. or R.C.E. Name ) ! - R.S. or R.C.E. No. { ; <br /> Test Location ( r; Test Date/Time <br /> } I {- <br /> 4. ❑ SANITATION PERMIT <br /> f Job Address/Location f f �! _ JET <br /> Owner 4 z s (Address <br /> ❑ SEPTIC TANK "ZDCES_SPO �• LEASHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0•(T,EMPOARY— .❑ NEW REPAIR 0 OTHER <br /> r ..:e 13 A`Gk <br /> S. ElCHEMICAL TOILETS For July 1�-J&re;3 .1 <br /> Type Construction ) -- Disposal Site } <br /> No. of Units _ 1 _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT`PLANT � r July 1 June 30, 19 ! - tr1 <br /> Operator Name t Where Certified <br /> Plant Location <br /> Plant Capacity = I No. Units Served <br /> 7. ❑ LAUNDRY- For July 1, -June 30, 19Via <br /> f�'ft fr ;s4 <br /> I i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. R <br /> I ) <br /> a '•C�a w,, t... <br /> I'hereby certify that I have prepared this'application and that the work will be do11 ne in accordance with San Joaquin County <br /> t <br /> ordinances, state laws, and rules and re latio of the Sari Joaquin Local Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> _ ) <br /> FOR DEPIRTMENT USE ONLY <br /> ' <br /> I i <br /> Fee Is Due: 11ANNUALLY ❑ PER NIT 11 PER SITE ❑EACH ❑ January 1 R Jeceived By January 31 ❑ JLily 1 &Receive By July 31 <br /> BASE EXPLANATION BILLING u REMITTANCEqEMIT <br /> $ t AMOUNT DUE CHECKED <br /> - - DATE �_ -DATE .,REMITTED - AMOUNT <br /> FEE - _ � , 4 <br /> LESS <br /> "PRORATION ,` S <br /> PLUS <br /> —PENALTY— <br /> OTHER .. ' �'-$�%CC-/4.., f <br /> OTHER <br /> Gno <br /> Received byDate peceipt No,' Peemit No, issuancd Date Mailed Delivered <br /> .APPLICANT-RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 570C7(TON;Cb.95201 <br />