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Applications Will Be Processed When Submitted ProperlyCompletes. rseJure 1w—a•• •• �� <br /> APPLICATION <br /> �. (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> c LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> y Business Name (DBA) rQ yq5 tU.� <br /> �� Fi 2 C j� �— Address <br /> a Owners <br /> J Firm Partners, Addresses and Telephone NumbersC:L 14 Emergency Telephone No. <br /> aI?s Telephone No-f-- <br /> -i <br /> Contractor Licence No. Date <br /> tr Title <br /> L Applicants Name (Print) al <br /> --Please check Applicable Category (1-7)and Fill in the Required Inlortnation <br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 1 `+. ❑ SANITATION PERMIT <br /> Z <br /> Job Address/LocationAddress <br /> Owner <br /> LEACHING FIELD 11 SEEPAGE PIT 13PACKAGE PLANT <br /> SEPTIC TANK 13 CESSPOOL ❑ REPAIR ❑ OTHER <br /> 10 PERMANENT 11 TEMPORARY <br /> � NEW �Q <br /> 1 <br /> 5: 13CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 pre r d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rut 1 1 MngulatiOn f the Joaquin Local alth District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due' ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly <br /> 31 <br /> BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE GHECKEt7 <br /> PATE DAT REM4TTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION t <br /> PLUS i <br /> PENALTY <br /> OTHER rI' <br /> OTHER <br /> f� <br /> /r � Pe Permit No Issuance Date Mailed elive d <br /> Received by pate Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA <br />