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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> "QUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the S n Joaquin Local Health District 1 <br /> N Business Name (DBA) Addresso <br /> zOwner /,,�,_�v�[ao6-le Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> R Business Telephone No. �� � �� Emergency Telephone No. <br /> a Q� <br /> Contractor Licence No. <br /> LApplicants Name (Print)—______ 114, Title ga /n !.y Date <br /> ~ � 1 <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 p <br /> For July 1, June 30, 19 1 <br /> No. of Vehicles Stared <br /> No. of Chemical Toilets Stored 1 `( <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. ❑ SANITATION PERMIT <br /> Job Address/Location rz '-V R—L> <br /> Own Address��� <br /> SEPTIC TANK CESSPOOL ❑ LEACHING FIELD D SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑'TEMPORARY ❑ NEW ❑ REPAIR ❑-OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ,r <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 <br /> Operator 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. <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 a 4e �oons o e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due[ ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACF1 ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 11s► <br /> PENALTY QJ <br /> I <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No _ Issuance Date Mailed Oe red <br /> 1 <br /> ( APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Bo=2009 ST CKTON.CA 95201 <br />