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Ai1F11r..111l+er4 411rotian i r.11 c. .::iri1 4i1}�li ..iiliiidh"I"I i.ullltTlblud He ,.11m TO SiUrl The Application. <br /> a. APPLICATION <br /> (For Non-Transferahle, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busines In the <br /> n jurisd�'ctional area of the <br /> Business Name (DBA) an.�Joaquin L.lo -i HIth District <br /> -L - C ress <br /> Owner <br /> Address �— <br /> J Firm Partners, Addresses aid Telephone Numbers Y <br /> CL <br /> Business Telephone No. r� � • A I Emergency Telephone No. <br /> Contractor Licence No. 01 <br /> � <br /> Applicants Name (Print) I�r . Title <br /> ate <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. <br /> Equipment Parking Address--- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ R.S.or R.C.E.No. <br /> Test Location _ _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location - <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD EPAGE PIT Q PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY W ❑ 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name — _ __-_ Where Certified <br /> Plant Location <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 /> Hornr,ownornl!icanneda ant's,:,: <br /> n r,f;,.• :• 1 nl lhr.wnr!;f�+r�hich this permit is is }� <br /> in such maner u <br /> ns ,1S to herornc hI 'o <br /> Contractor' hirinr; c. I .,. ' sue:rl,i s11n1i nnf eniploy any person <br /> �'� .. .. ..,."1!1e perf0'mdf'.%L'rt!hr.ernTk Ior;4!11Ch I!i,5;l�.n�.!!i5 ilsue;!.I Shall <br /> I hereby certify that have prepared this applicationnd that the work will be done in accordance with San Joaquin County <br /> ordinances state laws, rules ands�ulatift�han Joaquin Local Health District. <br /> APPLICANT'S SIGNATORC,_ �•,�- ___ ______ - _ <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <0 4S — -- <br /> LESS <br /> PRORATION <br /> PLUS - - - <br /> PENALTY <br /> OTHER <br /> OTHER -- - - --- --- 6 —, -- - - <br /> Received by D to Receipt No Permit No. Issuance Date <br /> d red <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,Aile�-7D <br /> oz 2009 TON,CA 95201 <br /> 1� <br />