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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Af"LICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) DAA F}�Q+�IZ I Sb( ��' � Address pd.Bax 14r <br /> aOwner Address <br /> Q.Firm Partners, Addresses and Telephone Numbers 1 <br /> C6 <br /> Business Telephone No. G — o Emergency Telephone.No. ` <br /> Contractor Licence No. <br /> Applicants Name {Print} dCJ Title 'q7-VOP— Date <br /> i <br /> Please check Applicable Category (1-7) and Fill in the Required Iniormafion <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. Licc'se Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 u, ` <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 Location Test Date/Time <br /> 4. 0 SANITATION PERMIT I <br /> Job Address/Location <br /> mag . -77ev <br /> �Owner p CO. Address PD <br /> 11r�f <br /> WI SEPTIC TANK CESSPOOL lal LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <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 ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d rules nd regulations of the San Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br />`r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE f 5-- <br /> LESS LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER <br /> OTHER <br /> �711a3 <br /> S <br /> Received by Date Receipt No- Permit No. Issuance Date Mailed elive ed <br /> -.. <br /> `'APPLICANT 'RETURN.AL•L COPIES TO:- ENVIRONMENTAL HEALTH.PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.�Box 2009 STOC TON,CA <br />