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Ov+ a VApiii4alp �ill Be Processed When Submitted Properly Completed. Be Sure robtgn inexppll.atiw— <br /> _ t APPLICATION �r�3 <br /> STP 7 1979 (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> J ENVIRONMENTAL HEALTH PERMIT <br /> SAN n r i''=s`�� )C" I' LIQUID WASTE <br /> �_ <br /> HAT14pc� o ��i�ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District C <br /> ,F Business Name (DSA) -- Address Ir , <br /> aOwner 0©ti S Address - <br /> Firm Partners, Addresses and Telephone Numbers ` >� <br /> a Business Telephone No. !L 2 Emergency Telephone No. <br /> -f <br /> 1 01 <br /> Contractor Licence No. <br /> Title Date <br /> LApplicants Name (Print) <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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 Location Test Date/Time <br /> 4. )Q SANITATION PERMI <br /> Job Address/ ocation IE <br /> Owner—AJs Address <br /> (�SEPTIC TANK E] CESSPOOL X LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction _ Disposal Sgite <br /> No. of Units Equipment Storage/Cleaning Location(s) rty <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19 t � <br /> Where Certified <br /> Operator Name J <br /> Plant Location �J <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. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <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, and rules and regulations of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRd By l July 31 <br /> BASE EXPLANATION BILLING REMITTANCE `b AMOUNT DUE CHECKED <br /> DATE DATE REMITTED r� AMOUNT <br /> FEE T +Qv <br /> LESS , <br /> s <br /> PRORATION F <br /> PLUS <br /> PENALTY <br /> } ` <br /> OTHER <br /> OTHER F1 <br /> © IZ--79 ) <br /> • <br /> y Date Receipt No. Permlt No. 9 Issua ce Date Mailed Dekivered <br /> Received b <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 5TOCKTON,GA 95201 <br />