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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t� <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> AppI icatio hereby ma a tb carry o siness in the jurisdictional area of th an Joaqui oca 11th Dis i t <br /> Business Name (DBA) E 1= Address .a <br /> a Owner Address <br /> Firm Partners, Addresses and le h e Numbers <br /> eBusiness Telephone No. 3.S Emergency Telephone No. <br /> Contractor Licence No. p <br /> L Applicants Name rtG Title Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. C <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 t1 <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. ❑ SANJATION PERMIlea <br /> I <br /> Job Add re /Loaa ' n D / /� -97 <br /> ..; tk <br /> Owner ddress o <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD &-SEEPAGE PIT ❑ PACKAGE PLANT <br /> P-PANENT 1 CIJEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS' For July 1, -June 30, 19 <br /> Type Construction Disposal Site f <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLAQfT For July 1, -June 30, 19 <br /> Operator Name. Where Certified O <br /> Plant Location ' 'r. <br /> Plant Capacity "j.- - ----- ``, No. Units Served __ i'I. '�• <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 /> Y I hereby certify that I have ared this application-an th a work will be done in accordance with San Joaquin County �fl <br /> r ordinances, state laws, an es and regulations of q Local Health District. <br /> APPLICANT'S SI <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT CJ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING �` REMITTANCE $ AMOUNT DUE CHECKED <br /> DATF.._; - DATE j REMITTED AMOUNT <br /> FEE L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> v <br /> OTHER <br /> OTHER D <br /> Y <br /> Received by Date Receipt No Permit No, ssuanc ate Mailed Iver d <br /> / APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,C 952131 <br />