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�'•�. . <br /> Applications Will Be!Processed When Submitted Properly Completed. BeSureTo Sign <br /> , � tj APPLICATION <br /> 3J0 (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is�eby de to carry on business in the jurisdictional area of the San Joaquin Local Heal h Distric� <br /> HBusiness Name (DBA) a Address �^ s <br /> a Owner <br /> l(,e IA � j�� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> E. Business Telephone No. Emergency Telephone No. <br /> • <br /> Contractor Licence No. �� a Date <br /> L Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill In the Required Information., p� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <br /> For July i, June 30, 19 Disposal Sites # <br /> G Description(Make/Yr., Color) <br /> CAL. License No. CAL. Liccrse Renewal No. <br /> Serial No. �1 3 <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 a <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> s <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> j] Test Date/Time <br /> Test Location <br /> 4. .K SANITATION PERMIT 3� { �. � R <br /> Job Address/Location { ��� <br /> Owner d Address rrww <br /> El SEPTIC TANK ❑ CESSPOOL 'XLEACHING FIREPAIR FIELD V SEEPAGE PIT ❑ PACKAGE PLANT "1 <br /> O PERMANENT ❑ TEMPORARY ❑ NEW <br /> 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <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 Where Certified <br /> Operator Name <br /> Ptant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> f ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have ared this application-and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,an rue land regulation of th1e'San oaquin-Local-Health District., <br /> APPLICANT'S SIGNATURE X <br /> y I <br /> FOR DEPARTMENT USE ONLY <br /> y <br /> Fee IS DUB: ❑ 'ANNUALLY PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 July 1 8 ReceivedREMITuIy 31 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT - <br /> FEE <br /> LESS <br /> I PRORATION t <br /> ` PLUS <br /> k PENALTY <br /> OTHER ' <br /> 'a pTNER - <br /> issuanc <br /> Received by <br /> Date Receipt No- Permit No. d e Date Mailed Deliv red <br /> V f <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 . STO TON,G 95 �_ <br />