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Applications Will Be Processed When Submitted Properly Completed. Be Sure TO Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable, Revocable, and Suspendablef SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,a <br /> LIQUID WASTE ' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> O Business Name (DBA) Address 07-0 �� y <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Tele�p^h�ne Numbers <br /> a -Telephone No. * ��� Emergency Telephone Na. <br /> Contractor Licence No. ) <br /> Applicants Name (Print) Date <br /> Title <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) �. <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. p <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored - f <br /> No. of Chemical Toilets Stored X17 �^ <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E..No.•- <br /> Test Location f . Test Date/Time \ <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc tion G/L � d <br /> T- <br /> owne - 'Address_F==G+. <br /> SEPTIC TANK. . ❑ CESSPOOL EACHING FIELD ❑ SEEPA!!Z-PIT ❑ PACKAGE PLANT r <br /> ❑ PERMANENT; PJTEMPORARY ❑ NEW ❑ REPAIft� ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction' Disposal Site <br /> Equipment Stora Storage/Cleaning Location(s) <br /> No. of Units i9 ; <br /> &. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> •> <br /> Where Certified <br /> Operator Name <br /> Plant Location 4 r <br /> No. Units Served <br /> Plant Capacity I <br /> 7. ❑ LAUNDRY For,:July 1,�-June 30, 19 <br /> SIZE: ❑ Less Than`1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 11 <br /> DRY CLEANING, Che icals Used/Amount/Mo. <br /> _ --..,-+.-•-sem <br /> I,herebyYcertify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,{state laws, and files and re latio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> 4 r l <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due:-C] ANNUALLY ❑ PER-UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> Z REMIT - <br /> ew BILLING REMITTANCE $ <br /> } BAS' `' EXPLANATION AMOUNT DUE CHECKED l <br /> PATE DATE REMITTED �J AMOUNT <br /> I! FEE Ce-m.�.- i e <br /> J <br /> LESS t <br /> PRORATION <br /> PLUS — <br /> PENALTY s - __�_ - -�• <br /> _ OTHER <br /> OTHER <br /> LIE <br /> Received by Date Receipt No. Permit No, ISsu nce Dat Mailetl veered —' I <br /> 1601 E�HAZELTON O-` <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERM ITISERVICES N. eB *Z 9� TOCK ON,CA 952(W .I <br />