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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 S as -z <br />Applica ion is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health Distrjgt_ <br />wBusiness Name (DBA)'- Oqq Address � � �• �C'K TN6R <br />, J <br />a Owner ov)e K MK' 49VP9-AikVL1 Address <br />Firm Partners, Addresses and Tele ne umbers <br />3. Business Telephone No.�y—� Emergency Telephone No. <br />REMIT <br />a <br />Contractor Licence No. <br />BASE EXPLANATION BILLING <br />REMITTANCE <br />S <br />Applicants Name (Print) C C Q[.�:12T/9,�:,L� Title Date <br />CHECKED <br />Please check Applicable Category (1-7) and Fill In the Required Information <br />DATE <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />REMITTED <br />For July 1, June 30, 19 Disposal Sites <br />AMOUNT <br />Description (Make/Yr., Color) <br />^ � y� <br />—5. 6 U k' k' <br />Serial No. CAL. License No. CAL. License Renewal No. <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />�s(� •(�� <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />Q <br />CIO <br />_ <br />No. of Chemical Toilets Stored - <br />3. C& PERCOLATION T T <br />C� <br />`- y�_ <br />R.S. or R.C.E. Name Y''y R' i17r1 R.S. or R.C.E. No. YCC 6 <br />UH V Sj ,` <br />- CC-> i <br />Test Location Test Date/Time�`'Of✓D� <br />4. ❑ SANITATION PERMIT _ <br />Job Address/Location <br />OTHER <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br />❑ PERMANENT ❑ TEMPORARY ❑ 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 />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name Where Certified <br />Plant Location <br />_ <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 <br />ordinances, state laws, and <br />APPLICANT'S SIGNATURE <br />this a Ication d the a ork will be done in accordance with San Joaquin County <br />P , <br />•eau 'ons of.tlle S aq n Local HealtVIDistrict. <br />r. <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 8 Received By July 31 <br />REMIT <br />BASE EXPLANATION BILLING <br />REMITTANCE <br />S <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />^ � y� <br />—5. 6 U k' k' <br />LESSULo� <br />�s(� •(�� <br />PRORATION <br />Q <br />CIO <br />PLUS <br />C� <br />PENALTY <br />7�Z <br />OTHER <br />OTHER <br />0 <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />