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Applications Will Be Processed When Submitted Properly Completed.Be SureTo sign I11etappacauu,1. <br /> APPLICATION <br /> - (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby made to carry on b siness in the jurisdictional area of the San Joaquin Local Heaith Di ict <br /> y Business Name BA} Address <br /> z Owner Address i <br /> a <br /> 21 <br /> Firm Partners, Addresses and Telephone Num rs <br /> CL Business Telephone No. °-)6J_ Emergency Telephone No. <br /> a r <br /> Contractor Licence No. <br /> L Applicants Name (Print) Ar_,5 T Q 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 k Disposal Sites <br /> Description(Make/Yr., Color)t <br /> Serial No. CAL. License No. CAL. Licc sse Renewal No. <br /> Capacity """ Gal.,-,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 •� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> R.S. or R.C.E. Name R.S. or.R.C.E.No. <br /> Test,Lo"tion Test Date/Time r�? <br /> 4. W SANITATION PERMITo <br /> -� <br /> Job Address/Location <br /> •' . c z�u <br /> Ow r _ Ad ress <br /> PTIC TANK ❑ CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> L�PERMANENT C3 TEM NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 +� <br /> I <br /> Type Construction Disposal Site 14. - _ <br /> No. of Units Equipment Storage/Cleaning Location(s) R <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ='Js r <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served" <br /> 7. 11LAUNDRY For July 1, -June 30, 19 ► 'p <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and urvo and regulation f t e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> l;,� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> i! BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION} DATE DATE REMITTED ,4/ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER b <br /> C�5133b 9 �7 <br /> Received by Date. Receipt No, Permit No. Issuance Date Mailed ive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOC TO ,C 952 <br />