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Applications Will Be Processed When Submitted Properly Gompietea, nebure to 019" tnr.+NN111,0%lull. <br /> APPLICATION <br /> s` (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati a eb a to carry bu s �h juri�ciicti nal area of the r rl,foaquir oal,�al ha strict <br /> OF Business N (DBA) Address <br /> ' Address C3 <br /> z Owner �} l /�R�st 1 [ Address <br /> I <br /> J Firm Partners, Addresses and Tele o umbers _ <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor licence No. 443, "j,IF <br /> Applicants Name (Print) -7'I 4 t Title Date <br /> Please check Applicable Category (1-7) and Fill 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) w-r <br /> Serial No. CAL. License No. CRL Licc Ise Renew a! No. <br /> Capacity Gal.,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 p <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Dation Test Date/Time <br /> 4. yLJ' SANITATION PERMIT <br /> Job Address/Location ) so N c" <br /> O rer � �4 f>M Address <br /> IBJ SEPTIC TANK CESSPOOL ��ACHING FIELD 11 SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY L� 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 /> 1J <br /> I hereby certify that I have prepared this application and that the k will be done in accordance with San Joaquin County <br /> ordinances, state laws, an and regulations of th n Joaqui oval Health District. <br /> APPLICANT'S SIGNATURE X <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 �.', !a S L___� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6 <br /> Received by Date Receipt N0. Permit No. Issuance Date Mailed Deliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STO TON,C 9 <br />