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Applications,Will Be Prressed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE t <br /> . ,. ENVIRONMENTAL HEALTH PERMIT <br /> t = <br /> LIQUID WASTE <br /> - <br /> Appl ication ' ereby mad to carry on business in the jurisdictional area of the San Joaquin Local Health Distri t <br /> rBusiness Name Aj ! e Address <br /> z Owner X <br /> b [� �`' A dress d <br /> 0 Firm Partners, Addresses and T I 'one Numbers <br /> a. Business Telephone No. — -S—-2-4 Emergency Telephone No. <br /> t d <br /> Contractor Licence No. <br /> Applicants Name (Print) 4TL_4lii;) Ar/A& Title Date C <br /> Please check Applicable Category 0-7) and Fall 1n the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y <br /> For July 1, June 30, 19 0- Disposal Sites <br /> Description(Make/Yr., Color) A; <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> Capacity IMI Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 h' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored i <br /> l 3. ❑ PERCOLATION TEST II I <br /> R.S. or R.C.E. Name I R.S. or R.C.E. No. <br /> I Test Loca n �I Test Date/Time I <br /> r 4. ANITATION PERMIT I�I (� {� N <br /> Job Address/Location (3 Q C t 4' <br /> Owner . ei Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL C1 LEACHING FIELD C1 SE�.AGE PIT El PACKAGE PLANT 4 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW U' EPAIFt 11 OTHER <br /> 5. 11CHEMICAL TOILETS For July 1, -June 30, 19 _ <br /> Type Construction �u Disposal Site <br /> No. of Units I� Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1 -June 30, 19, <br /> Operator Name HMI Where Certified <br /> Plant Location IMI yJ + s <br /> Plant Capacity 'III _ No. Units Served a s } <br /> 7. ❑ LAUNDRY For July 1, -June 30,=19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft_ ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> 1 <br /> 1 <br /> � l <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, Bind r es and regulations he n Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br />, a <br />` ) FOR DEPARTMENT USE ONLY <br /> Fee Is Due., ❑ ANNUALLY :�© PER UNIT ICL PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received'By July 31 <br /> REMIT <br /> BILLING REMITTANCE $, <br /> BASE I� EXPLANATION,. . DATE DATE REMITTED AMOUNT DUE CHECKED <br /> J AMOUNT <br /> FEE ill ✓!] � 1/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> h <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `II <br /> F <br /> l <br /> q <br /> III os�� -30 <br /> I Received by _ Date I1, Receipt No. Permit No- I sua ce Date MaiIWc_1 ____T Delive d <br /> APPLICANT—RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES. `'" 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,CA 95201' <br />