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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> _ Application ; ere y m e to carry o buss a the jurisdi tional area of th an qwn Locaal"ealth Di rict <br /> Business Name (DBA) ddress --� -' <br /> i Owner Address - -.__.---_-- -- <br /> a 1 <br /> J Firm Partners.Addresses and T� hon u bers --— <br /> aBusiness Telephone No. - T� ' _ —. Emergency Telephone No. <br /> Contractor Licence No.��`_.Q.._ r� c <br /> �Applicants frame (Print) V��� /E� O Title �S Oate <br /> Please check Applicable Category(1-7)and Fill In the Required Information 1 <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 <br /> Capacity Gat..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 <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test ocat;on Test Date/Time <br /> 4. SANITATION PERMIT „ ", <br /> Job Add r /Location `l -""- X <br /> Owner Addreyss�rVI <br /> SEPTIC TARK ❑ CESSPOOL LEACHING FIELD p.SE£PAGE PIT ❑ PACKAGpPLAN <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR OTHER S'E'PIA" e"J'416'Sy6TE N) <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> )e Construction_ Disposal Site <br /> Nd.of Units Equipment Storage/Cleaning Location(s) — _ -- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name _.— Where Certified Jul.Plant Location C <br /> Plant Capacity No. Units Served y <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 /> hereby certify that I have prepared this ap lication and that the work will be done in accordance with Soman Joaquin County <br /> ordinances,state laws,and es an re ul t, ns of the aqui al Health District. { <br /> APPLICANT'S SIGNATURE X C <br /> y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due, ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 li Received By January 31 ❑Jury t &HeGe(Ved By JWy 31 <br /> REMIT <br /> T:�BASE EXPLANATION BILLING REMITTANCE I AMOUNT DUE UTDAT£ DATE REMITTED 9,E�KEO <br /> UNT <br /> FEE <br /> LESS <br /> PRORATION s <br /> PLUS — - <br /> PENALTY <br /> OTHER <br /> — I <br /> OTHER <br /> Rece!ved by Date Receipt No, Permit No Issu nce Date Malletl Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL REALT41 PERMIT/SERVICES 1841 E.HAZELTON AVE., .eo><20x9 SYOCKTON.CA 95241 11 <br /> I' <br />