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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> � f <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <br /> l ENVIRONMENTAL HEALTH PERMIT i <br /> LIQUID WASTE <br /> Application is hEireby made to carry on business in the jurisdictional area of them Jo uin Local Health Di i�ct� ) <br /> yBusiness Name (DBA) Address - /(' <br /> z Owner Address <br /> J,Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. z — I L <br /> L Applicants NamTitle f Date / - d -- <br /> Please check Applicable Category (1-7) and Fill in the Required Information `10 <br /> I <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 J ' <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. f SANITATION PERMIT CA <br /> Owner <br /> Job Add ss/Location �� ' � Q+� �� <br /> Owner�i�Ct '�iC'Ti1 TT/�t� �� Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD RISEEPAGE PIT ❑ PACKAGE PLANT <br /> 21'ERMANENT ❑ TEMPORARY OtEW 19-REPAIR a—OTHER 5i4AIP � Q�1 '-r<A-r <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 y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. <br /> F ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 hereby certify that I hav prepared this application and t the work will be done in acco ante with/,S n County <br /> ordinances, state la and ulations e 5 Joaqui Local Health District. <br /> APPLICANT'S SIGNATURE X " <br /> �I <br /> FOR DEPARTMENT USE ONLY <br /> 1 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ,PER SITE ❑ EACH ❑ January 1 &Received By Ja31 ❑ July 1 &Received By July 31 <br /> f BILLING REMITTANCE REMIT <br /> I BASE EXPLANATION AMOUNT DUE CHECKED <br /> flr DATE DATE ITTED AMOUNT <br /> FEE .L� .. <br /> LESS <br /> PRORATION <br /> PLUSi <br /> PENALTY -d10000 <br /> fi <br />} OTHER <br /> 1 - <br /> OTHER <br /> d000r .21 <br /> Received by Date - ---' Receipt No Permit No Issuance Date. Mailed elcared <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON-AVE.,P.O.Box 2005 STOCKT N.CA 95201 <br />