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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign Tne ApplIGUXTUM .•- .� <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i herebyr a to arryT business in the jurisdictional area of the San Joaquin L I Heal strict <br /> w Business Name (DBA) CL r Address 1&-- / <br /> i Owner Address <br /> -a �— <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> a. Business Telephone No. " f <br /> Contractor Licence No41 L . <br /> jApplicants Name (Print) <br /> Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information Q <br /> E 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) \1. <br />- Disposal Sites <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License Renewal'No, <br /> Serial No, <br /> 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'Location Test Date/Time - T <br /> 4. ❑ SANITATION PERMITlye <br /> 1 <br /> Job Address/ ovation Ad <br /> L° <br /> Owner Address <br /> O i <br /> ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESS POOL LEACHING FIELD <br /> 11 REPAIR ❑ OTHER <br /> PERMANENT ❑ TEMPORARY NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction t Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT IFor July 1, -June 30, 19 Where Certified ss <br /> Operator Name <br /> i <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., 0 More Than 1,000 Sq. Ft. <br /> 11DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 . <br /> I hereby certify that I have pre=pared-this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a r les and a lati ns of the S Joaqu Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 - "_.t I ,. ,vf FOR DEPARTMENT USE ONLY <br /> El 1 &Received uIy 31 <br /> { Fee Is Due: C1 ANNUALLY' ❑ PER UNIT I PER SITE ❑ EACH ❑ January 1 &Received By January 31 REMIT <br /> N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> y PENALTY <br /> f OTHER <br /> ' OTHER <br /> Ol -7 9—a o <br /> z v i Receipt No. <br /> Received by Date Permit No Issuance ate Mailed Deliv ed _ <br /> AL HEALTH PERM 1601 E.HAZELTON AYE.,P.O.Bax 2009 STO TON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENT01 <br />