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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 /> r LIQUID WASTE <br /> Applicati 'is her by made to car o usiness in the jurisdictional area of the Jo quin Local Health ' tri � <br /> N Business Name (DBA) AA 6/¢ 11rz I G• Address <br /> z Owner Address_- <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - — ? 3 Emergency Telephone No. <br /> Contractor Licence No. <br /> r L Applicants Name (Print} a f�tr.t Title Date —�� <br /> Please check Applicable Category (1-7)a d Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites f1 <br /> Description(Make/Yr., Color) v <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 /> I' No. of Chemical Toilets Stored <br /> F 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 iR <br /> Job Address/Location <br /> < �'• 4 <br /> Own L Address <br /> J I`SEPTIC TANK ❑ CESSPOOL ErEACHING FIELD C"fi SEEPAGE PIT C1 PACKAGE PLANT <br /> �PERMANENT ❑ TEMPORARY 2 4EW 13 REPAIR ❑ OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 y ` <br /> N <br /> I, Type Construction _,Disposal Site n ` <br /> + No. of Units Equipment Storage/Cleaning Locations}" G <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> f Operator Name Where Certified <br /> Plant Location I! <br /> Plant Capacity No. Units Served w - <br /> IL 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I.have prepared.,this application and that Pe work will be done in accordance with San Joaquin County <br /> ordinances, state laws,Od rules and rqlgulations of San aqui Local Health District. <br /> k <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 &Received By July 31 <br /> REMIT <br /> 4 BILLING REMITTANCE _ $ <br /> SASE <br /> �EXIFLAN , ION DATE DATE REMIT A OUNT DUE CHECKED <br /> AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> S PLUS <br /> PENALTY <br /> OTHER <br /> 4 - <br /> OTHER <br /> 00, <br /> h Received.by Date' Receipt No Permit No. Issuance Date Mailed Delivere. <br /> STOCI4Te�ON,GA 5201 <br /> � �` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 y <br />