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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i° <br /> APPLICATION <br /> 4 (Far Non-Transferable, Revocable, and Suspendable) SEPTAGE `G <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> I: r1 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin L al Health Distr'ct <br /> mBusiness Name (DBA) Address- � <br /> a Owner; 1� A' Address j <br /> D Firm Partners, Addresses and®Teleplhone Numbers - <br /> a Business Telephone No. p� 7�-Q1 Z Emergency Telephone No. <br /> a <br /> Contractor Licence No. I <br /> Applicants Name (Print} h Title a Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERM ltjR EG ISTRATIO N (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 H Disposal Sites <br /> Description(Make/Yr., Color) I� <br /> Serial No. lM CAL. License No. CAL. License Renewal No. I <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking AddressI� <br /> 2. 11PUMPER YARD <br /> For July 1, June 30, 19 I l <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored IM <br /> 3. Ill PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location IM Test Date/Time <br /> 4. Ed SANITATION PERMIT I�- <br /> Job Address/Location <br /> IOwner jM Address <br /> ��I <br /> sal SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY ❑ NEW 11 REPAIR ❑ OTHER <br /> 5. Cl CHEMICAL TOILETS For�July 1, -June 30, 19 <br /> r - <br /> Type Construction Disposal Site <br />` �M Equipment Stora Storage/Cleaning Location(s) <br /> No. of Units9 9 O _ (� <br /> _ 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name I�' Where Certified �J <br /> Plant Location <br /> I 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t• 3N <br /> I I hereb certify that I ave prepared this application and that the work will be done in accordance with San Joaquin County <br /> Y Y <br /> ordinances, state laws, an les and regulations of thet.San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X . �' - <br /> c I � <br /> II l <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 5 &Received By January 31 ❑ July 1 &Received By July 31 <br /> }Np REMIT <br /> BASE�I, EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> .I, DATE DATE REMITTED AMOUNT <br /> � FEE <br /> #-q5,11-c)(2 i <br /> [���rrr 5 <br /> LESS I� - <br /> rr PRORATION <br /> f PLUS I� <br /> PENALTY <br /> }} OTHER <br /> F OTHER <br /> .�� 9 a -7 C�3 1 <br /> Received-by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> k ,N ti <br /> APPLICANT—RETURN ALL COPIES TO: . ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E:HAZELTON AVE.,P.O.60:2009 STOCKY N,CA 95201 <br />