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—x <br /> Y Applications Will Be Processed When Submitted Properly Completed. BeSureTosign <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 411 <br /> LIQUID WASTE <br /> Application is here ma d6carry on busin in the jurisdi�c tonal area of the S�3�oa'lLocal �th Di i t <br /> ddress �/ <br /> OF-Business Name (DBA) <br /> # Address <br /> l'- <br /> Owner <br /> J Firm Partners, Addresses and J Telephone � Emergency Telephone No. <br /> ILBusiness Telephone No. `� _ 3 J <br /> Contractor Licence No. 3 9 <br /> Date oc� <br /> L Applicants Name(Print) <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 /> 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 /> I! 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.G.E. No. <br /> t R.S. or R.G.E. Name <br /> Test Loc Ion Test Date/Time <br /> i <br /> 4. E SANITATION PE <br /> Job Address/LocationrZ�" <br /> Owner Addre <br /> FIELD ` 0 SEEPAGE PIT 13ss <br /> SEPTIC TANK ❑ CESSPOOL LEACHING PACKAGE PLANT <br /> t3 <br /> ' ��,,// El REPAIR <br /> ❑ OTHER <br /> Q' <br /> PERMANENT ❑ TEMPORARY ' KNEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-'June 30, 19 <br /> Disposal Site <br /> Type Construction a <br /> No. of Units Equipment Storag16- e/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> I Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> ik <br /> 7. ❑ LAUNDRY For July 1, -June 30; 19 <br /> r 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 t at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules an egula • of the S Joaglii �Localealth District. <br /> f <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT,USE ONLY <br /> Fee IS DUB: E3 ANNUALLY PER UNIT PER SITE Cl EACH ElJanuary 1 &Received By January 31 ❑ July 1 &ReceiveRd EMIT By July 31 <br /> EXPLANAT ON BILLING REMITTANCE - r.� $ AMOUNT DUE CHECKED, <br /> BASE DATE DATEREMITTED AMOUNT <br /> FEE ep <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY CI <br /> 1 _ <br /> t OTHER <br /> OTHER <br /> Receipt No. Permit No. Issu nce Date Mailed Del ere <br /> Date <br /> Received by 1601 E.HAZECTON AVE.,P.O.Box 2009- STOCK N,GA Ot <br /> `• APPLICANT—RETURN ALL COPIES To-.' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />