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y 4N ' 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 i ereby mad to carry on business in the jurisdictional area of the San Joaquin Local Heal D' trict 4 <br /> J Business Name (DBA) ��' E .S !/KE Address `S' �'�� C* <br /> zOwner <br /> ,41 <br /> Address <br /> 4 <br /> Firm Partners.Addresses and Telepne Numbers i <br /> Emergency Telephone No. <br /> a Business Telephone No.—T <br /> Contracto;Licence No. Lay�td—7 <br /> c Applicants Name(Print) <br /> /�' ate <br /> Title D <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VENICE£PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. <br /> CAL,License No. CAL.License Renewal No. <br /> Capacity # �Gal.,Weights&Measures No. <br /> ZA <br /> I Equipment Parking Address 1 <br /> 2. Q PUMPER YARD CIO <br /> For July 1, June 30, 9,— — <br /> No.of Vehicles Stored <br /> i No.of Chemical Toilets Stored <br /> f 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 /> f 4. VSANITATION PERMIT <br /> Job Addres location _ _ _ d �.,. — — <br /> Owner �� � � Address �� i <br /> 13SEPTiC TANK ❑ CESSPOOL 11LEACHING FIELD OSEEPAGE PIT ❑ PACKAGE PLANT11 <br /> v <br /> PERMANENT ❑ TEMPORARY NEW 13 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICALiTO1LETS For July 1,-June 31P,19 t <br /> u <br /> 1'ype.Construction Disposal Site <br /> No. of Units I EquipmentkStorage/Cleaning Location(s) <br /> l 6. ❑ PACKAGE TREATMENT PLANT For July I-June 30, 19 <br /> t. Operator Name I 1 Where ertified <br /> Plant Location I � <br /> Plant Capacity r "� No.Units Served l <br /> 1 +-� A <br /> 7. ❑ LAUNDRYEgr.�uly 1-- lune•30,-1.9: "—"! '� <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000,Sq.Ft. # <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. # <br /> ared this a licatlon and that�h,work will be done in accordance with San Joaquin CountyI hereby certify that l ep ppr <br /> i ordinances,state la s,and and regulations the S Joa4uin Local Health District. <br /> 6 APPLICANT'S SIGNATURE X 'l <br /> V# _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: '❑ ANNUALLY [3 PER UNIT Iv PER SITE ❑ EA6 .# ❑ January 1 8 R@Ceiv d By January 31 ❑ July t &Received By July 31 <br /> I REMIT <br /> IaILLING y REMITTANCE S AMOUNT DUE' CHECKED' <br /> BASE EXPLANATION I DATE DATE REMLTTED AMOUNTp <br /> FEE <br /> LESS - •� -,_..�, .�. -. <br /> PRORATION. <br /> PLUS 'fir-+w�+•+ ...,.+;� .. - �...... ..• ��..{ <br /> PENALTY + <br /> OTHER <br /> OTHER f I <br /> Received by - Date Receipt No. Permit No. 1 nce Da Mailed i ad <br /> APPLICANT—RETURN ALL ODPIES•TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> t601 E.HAZELTON AVE.;P.O.Box 20ce ST TON, ?Dt <br />