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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> M (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LiQUID WASTE <br /> Appl ication vlereby ma o carry on busin in the jurisdictional area of the Sap Joaquin LocaLHealth District <br /> LC <br /> F <br /> Business (DBA) -0-e-7 'Address <br /> i Owner p �, "' Address Q. <br /> J Firm Partners, Addresses and Telephone Numbers f <br /> Q. Business Telephone No. <br /> _ � T Z�./•� _ Emergency Telephone No. <br /> d Contractor Licence No. <br /> Applicants Name (Print) J�� , . rirTitleE• '� - Date <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 1, June 30, 19 — Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. F <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <br /> For July 1, June 30, 19 r <br /> No. of Vehicles Stored <br /> _ 7 <br /> No. of Chemical Toilets Stored s <br /> 3. ❑ PERCOLATION TEST E - <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. VSANITATION PERMIT <br /> Job Address/ cation <br /> Owner Address <br /> ❑ SEPTINK ElCESSPOOL LEACHING FIELD ❑ SEEPAGE PIT C1PACKAGE PLANT lh <br /> ❑ PERM ENT 13 TEMPORARY ❑ NEW XR <br /> EPAIR ❑ OTHER v\ <br /> 5. E] CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 'e1 <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> O rator Name Where Certified- <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> l <br /> i <br /> I hereby certify that I have prepares this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule regulations of the n Joaquin Local Health District. <br /> w � <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION � `DATF" TE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE g� <br /> LESS '" m <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> JV r <br /> OTHER <br /> Received by Date r Receipt No. Permit No. I suan a Date Mailed Delivers <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCK ON,CA 4 201 <br />