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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION -71- <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f LIQUID WASTE <br /> Applicati is hereby r e to car vn business in the jurisdictional area of the San Joaquip Local Health District <br /> yBusiness Name (DBA) © �' �` Address 17,0 '3P _ ` <br /> z Owner ` Address S Y <br /> t Firm Partners, Addresses and Telephone Numbers <br /> t` Business Telephone No. - l Emergency Telephone No. <br /> a <br /> Contractor Licence No. S <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights R Measures No. <br /> Equipment Parking Address Wit» r s <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 " <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. �^ <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT <br /> Job Addr ocation � Y <br /> Owner <br /> Address <br /> C1SEPTIC TANK 1:1CESSPOOL §KLEACHING FIELD 1WSEEPAGE PIT El PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,--,lune,30, 19 <br /> Type Construction f :T' Disposal Site <br /> No. of Units ° Equipment Storage/Cleaning Location(s) <br /> ' <br /> 6. 11PACKAGE TREATMENT PLANT mor J lu y 1, -June 30, 19 t' <br /> Operator Name ' " Where Certified <br /> ? Plant Location', <br /> rx r l <br /> -x <br /> !y:�', No. Units Served + t <br /> Plant Cap aclt nd _ <br /> 7. ❑ LAUNDRY For July 1, -Ji-rhe 30, 19 <br /> i <br /> SIZE: ❑'Less Than 1,000 Sq. Ft.t-f'04M1A ore Than 1,000 Sq. Ft. � I <br /> t ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ) '' <br /> l <br /> J+ t <br /> r t <br /> I hereby certify that I have-prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,,I, les and regulatio s of the n Joaquin Local Health District. t <br /> APPLICANT'S SIGNATURCX ---- — --- - -- ! <br /> i FOR DEPARTMENT USE ONLY <br /> � Fee Is Due: ElANNUAi'LL-Y­ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By duly 31 <br /> REMIT <br /> I r BILLING REMITTANCE $ <br /> BASE; EXPLANATION AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED AMOUNT <br /> FEE ... � . <br /> LESS i <br /> PRORATION r - <br /> 1 PLUS rl rt <br /> PENALTY ` <br /> OTHER <br /> OTHER / <br /> Received by - Date Receipt No - Permit No. Is uance Date _ Mailed Deli _red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009_ STO KION,CA 95201 <br />