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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION A# <br /> t. of Non-Transferable, Revocable, and Susnendab4.. SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT , t <br /> LIQUID WASTE <br /> Application is h reby ade to n business in the jurisdictional area of the an Joaqui Local Healt (strict ..-- <br /> „Business Name (p8�)-� �- �1 --� Ad r ss LeC <br /> Owner ✓ •�/ �• /4 'A�_90 Add esss L7ZC35 7/c0 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ___ Emergency Telephone No.— <br /> � Contractor Licence No. _ <br /> �Applicants Name (Print. Title Date " 2 <br /> Please check Applicd6le Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 3p, 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. I (PERCOLATION TEST <br /> R.S. or R.C.E.Name lY - R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATIONRMI n� <br /> Job Add ress/Location d l/t/ ! J Q <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 /> 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 prep4ed 'sapplic ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and a a 'o of the San Jo <br /> .Local Health District. <br /> APPLICANT'S SIGNATURE X ----- <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT OUE CHECKED <br /> DATE DATE REMITTED <br /> - AMOUNT <br /> FEE <br /> LESS --- -- - . <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> W�� �7 <br /> Received by Date Receipt NO. Pvrmil No Icguanne Hale millised pelWnvrtA <br />