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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> if APPLICATION 'oo <br /> i. jr Non-Transferable, Revocable,and Suspendabe SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h reby ade to n business in the jurisdictional area of the an Joaqui�I Healt I�t <br /> HBusiness Nam�e� )_ - —1 a---- �gAd r ss <br /> Owner_s - Ad es 5� W• _ ��O f -- <br /> Firm Partners, Addresses and Telephone Numbers ----- <br /> aBusiness Telephone No. —.— Emergency Telephone No. �_- — -- <br /> Contractor Licence No..-- -------- ---- — - <br /> LApplicants Name (Print) 1AWS,, Z.: -_-- Title _.__ __ Date -Z� — <br /> Please check Applicable Category(1-7)and Fill In thg 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 ---No. of Chemical Toilets Stored _ — — ---- — <br /> 3. �X PERCOLATION TE <br /> R.S. or R.C.E. Name __. / ��,�•C� R.S. or R.C.E. No. — ---- -- <br /> Test Location ____ --__.— _�Teesst Date/Time <br /> ❑ SANITATION RMI <br /> J <br /> ob Address/Location ---- <br /> Owner -_— _-- -- ---- ---- _ Address_ --.--- — <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL 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 <br /> Operator Name —. --------— ---- -- ---- _____ Where Certified —_ <br /> Plant Location - — --- - — -- -- ---� ---- ---.. --- — <br /> Plant Capacity_—_—_-_---___----___— _.—____ No. Units Served <br /> 1 7. ❑ LAUNDRY For July 1, -June 30, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.. ❑ More Than 1,000 Sq. Ft. (_ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ —. -- — — --- <br /> ENu1RChVib\1_1AL HEALTH <br /> FERMjTX�E�1 9 <br /> ! hereby certify that I have prepared s applic ion and that the work will be done in accordance I uin County <br /> ordinances, state laws, and fan r ula 'o of the San Joaquin.Local Health District. <br /> APPLICANT'S SIGNATURE X ------------ -- — )v ---- -----— — - ----- <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> f� DATE DATE REMITTED AMOUNT <br /> FEE------- o <br /> — <br /> LESS <br /> PRORATION - <br /> - h- <br /> PLUS $ <br /> PENALTY • C <br /> OTHER <br /> OTHER <br /> t Flo.n,..M 1+.. n,.,,. Aon....:e M•, n...m.l Nr !..c. iln!k A#a.!A".ri nq!oL£IIAd <br />