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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />.r Non -Transferable, Revocable, and Suspendab,-, SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />,rinn Is nwanv maria to narry nn husiness in the jurisdictional area of the.San JDaquin).Qcal Uri jstrict-- <br />r Business Name DBA) —J! k. / dress <br />Z_ t v r� -" r <br />? Owner-f�l�ii ddress <br />Ld <br />L >f <br />a <br />Firm Partners, Addresses and Teigpluong.umbers <br />C, Business Telephone No. Emergency Telephone No. <br />Licence No. <br />Contractor <br />V I 2 <br />L Applicants Name (Print) I r r I bi Title <br />I Date <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />REMITTANCE <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />AMOUNT DUE <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. CAL. License No. <br />CAL. License Renewal No. <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address <br />FEE <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />Vehicles Stored <br />No. of <br />LESS <br />No. of Chemical Toilets Stored <br />ON TE IL(Cw <br />3. ❑R.C.E.R.S. <br />rr, <br />No. ec <br />jj'' R.S. or R.C.E. <br />or R.0 Name/ <br />Test Location — 4C7C Test nate/Time <br />/ z <br />4. 11SANITATION PERMIT S —&L) __ <br />' <br />Address/Location <br />Job <br />Owner Address <br />PLUS <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGEPIT❑ <br />PACKAGE PLANT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br />❑ OTHER <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />PENALTY <br />No. of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name <br />Where Certified <br />Plant Location <br />OTHER <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 />OTHER <br />❑ DRY CLEANING, Chemicals Used/Amount/i <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 rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />/+ <br />r— x-/25185 <br />Receivetl by Dae Receipt No. Permit No. Issuance Date Mailed Delivered <br />.......... . ...... — —.,e.. ....... — ,...,.... ... ". — ..m a u.oen mu Ave en n... onnn emnrrnu nA oaem <br />■ <br />