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Ap icatlons Will Be Processed When Submitted Properly Completed. Be Sure To'Sign The Application. <br /> APPLICATION <br /> (For Nonjransferable, Revocable, and Suspendable) <br /> ENVIRO:NMENTAL,HEALTH PERMIT SEPTAGE <br /> TACE <br /> LIQUID WASTE <br /> Applicati is hereby made to carry o siness in the jurisdictional area of the San Joaquin al th Distr' #/ <br /> H Business a (DBA) E'er t9aw— Ad ress a_ <br /> aOwner. Address 6441C, <br /> J Firm Partners, A dresses and a ho6b Numbers . <br /> CL <br /> Business Telephone No. �S �� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) i Title Date r <br /> Please check Applicable Category(1-7)and Fall 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 /> Serial No, CAL. License-No. €: ! CAL. License Renewal No. <br /> Capacity- Gal.,Weights &Measures"N61 < `µ - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD j <br /> For.Ju'ly,1, " = June 30, 19 f, <br /> No. of'Vi6hicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> f <br /> R.S. or R.C.E. Name t R.S. or R.C.E. No. � 11•. l <br /> Test Location -Test..Date/Time_._ <br /> 4. ❑ SANITATION PERMI <br /> Job Ad s/Location 3�w WA 0,0�_ 12 <br /> Owner A ress <br /> SERTIC TANK Z-C,E SPOOF uMf A`r VACHING FIELD ❑ SEEPAG PIT ❑ PACKAGE.PrANT ` <br /> 99'PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r i <br /> Type Construction Disposal Site <br /> a <br /> No. of Units Equipment Storage/Cleaning Location(s) ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name w~,f Where Certified r <br /> Plant Location r ' <br /> Plant Capacity �` No. Units Served <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 /> I hereby certify that I have pre red this application: t the work will be done in accordant' with San Joaquif� unty <br /> ordinances, state laws, an s and re ulatioLo al ealth District. 1 y <br /> APPLICANT'S SIGNAT <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITS `. tR PER SITE ❑ EACH ❑Janu y '&lcceived By January 31 [I July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION �� "BILLING I REMITT E $ AMOUNT OUE CHECKED <br /> "DATE DA REMITTED AMOUNT <br /> FEE , r <br /> SJ <br /> LESSs' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6,5qC2 q <br /> }Received by Date Receipt No. Permit No. Issutince Date. Mailed Deli red <br /> APPLICANT—RETURN ALLCOPIESTo: ENVIRONMENTAL HEALTH PERMIT/SERVICES - -1601 E.HAZELTON AVE.,P.O.Box 2009 ST KTON, A 95201 - ` <br />