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Applications Will Be Processed When Submitted Properly Completed. Be SureTosign 1neAppncaIIUn. <br /> 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 /> m Business ame (DBA) Address A�I►S FIIJ <br /> SC,A+`Gti1. <br /> z Owner Qt Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aEmergency Telephone No. <br /> a Business Telephone No, <br /> Q <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title Date, W <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 •f <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored " , �~ <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name l • R.'§. or R.C.E.Np. <br /> Test Location _ Testy`pateu/ <br /> 4. ❑ SANITATION PER IT ' .y <br /> Job Add -s/Location 7o 6 <br /> Owner Lz•t Address- <br /> ,�, PTIC TANK ❑ CESSPOOL LEACHING FIELD i R SEEPAGE PIT ❑ PAC_KAGE P NT!� <br /> l!1•PERMANENT/E ❑ TEMPORARY C'�NEW f ❑'REPAIR ` OTHER /I ✓ ��a'� S�SrE/�4 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning iocation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified o <br /> Plant Location <br /> No. Units Served { <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 0-Less-Than 1,000 Sq- Ft.,- ❑'More Than 1,000 Sq. Ft. 3 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r— Az ggLrv44 S1Te`C TA�tI.K s c <br /> spS' b., 44k- r 33 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordane with San Jo in County <br /> ordinances, state laws, rules regulations of a an Joaqui Local Health District. I�g� <br /> r <br /> 17 <br /> APPLICANT'S SIGNATURE X <br /> iFOR"DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER ATE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION I BILLING REMITTANCE $ AMOUNT DUE ' CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 5�v <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS n <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0-1 26 Ss 13 8X10 la <br /> Received by Da Receipt No. Permit No. Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEI VP P.O.Box 2009 STOCKTON,CA 952 <br />