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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 0. APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District,_. <br /> Business Name (DBA) ? AA372lL47-lorJ Address ST $7TCss� <br /> i Owner -`" <br /> a Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. _4&S'31-71 a - _ - Emergency Telephone No.-. <br /> Contractor Licence No. <br /> LApplicants Name (Print) . 4_0 kl. <br /> u,L>'4�e D :- Title ' <br /> Date �PZ <br /> Please check Applicable Category(1-7).and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For July 1, June 30, 19 f - Disposal Sites. <br /> Description(Make/Yr., Color) 1 <br /> Serial No. CAL. License No. ` CAL. License Renewal No. <br /> Capacity Gal:;Weights & Measures No. y <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 4 R.S.or R.C.E. No. <br /> Test Location <br /> Test Date/Time <br /> 4. x�l SANITATION PERMIT `r f <br /> Job Address/Location 1.2- 3� L . 45 46D dl'!q <br /> Owner Address <br /> ' 'err/ <br /> SEPTIC TANK ❑ CESSPOOL qly,�/LEACHING FIELD 1:1 SEEPAGE PIT 1:1 PACKAGE PLANT <br /> PERMANENT 1:1TEMPORARY �t NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 c� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For Juiy 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> T. ❑ LAUNDRY For.July 1, -June 30, 19 1 a t <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 prepared this application and that the work will be.done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due. ❑ ANNUALLY PER UNIT _❑ PER SITE ❑ EACH ❑ January 1 &Received ByVanuary 31 ❑ July 1 &Receivkd By July`31— t, <br /> BASE EXPLANATION BILLING REMITTANCE $ ; _ - !REMIT ;. <br /> DATE DATE REMITTED . AMOUNT DUEOAN <br /> _. <br /> FEE / Il <br /> LESS <br /> PRORATION • .y r _PLUSPENALTY ' <br /> OTHER ' <br /> OTHER <br /> q <br /> Received b ' <br /> Y Date Receipt No. Permit No. f Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTIH�PERMIT/SEW/ICES # 1601 E.HAZELTON AVE.,P.O.Box 2009SSTOCI(T N,CA 95201 <br />