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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application hereby m�adse� to car o�nlb�usiness in the jurisdictional area of the San Jo�puiALocal Ith District <br />y Business Name (D A) W- MA9Yn�► � /7zG.S' Address �LI$�'{�• �� <br />a Owner 1)Q.rV� It�l®� Address i1iei O i -M% 1 4,dr1 <br />Firm Partners, Addresses and elephone Numbers �- - ��Yll 1�� c�—✓ <br />E. Business Telephone No. �y� �3u s✓ Emergency Telephone No. <br />a <br />Contractor Licence No. <br />L Applicants Name (Print) 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. <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 heroical Toilets Stored <br />3. <br />No. <br />RT )� �/I or/ <br />R.S. or R.C.E. N y ;i]1�lYi�G� %• /TI �� Z—L %% R.S. or R.C.E. No. Z.7�- JLC- o <br />Test Location "Allli&e lftg? l ssT Test Date/Time <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br />S. ❑ 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 <br />Date <br />CAL. License Renewal <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 prep <br />ordinances, state laws, and rules <br />APPLICANT'S SIGNATURE X (-- ' <br />LI PACKAGE PLANT <br />❑ OTHER <br />Where Certified <br />application and that the work will be done in accordance with San Joaquin County <br />ations of the San-JOaauln Local Health District. <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 <br />EXPLANATION BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED'' <br />AMOUNT <br />FEES <br />LESS <br />PRORATION <br />PLUS <br />7 <br />PENALTY <br />OTHER <br />OTHER <br />Rec O _by Data Receipt No. Permit No. Issuance Date Mailed Delivered <br />..... ......,.,...,..,.... ........oe. rnu... nn e..-. nTnr•rTnu re osom <br />PLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL Y <br />