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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 busine in the jurisdictional area of the Sa Jia ui cal�,ie lath District . <br /> OF Business Name (DBA) Address (� :. <br /> z OwnerAddress <br /> Firm Partners, Addresses a elephone Num ers <br /> CL Business Telephone No. 5 Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants-Name;(Prinf)'3! •-•Title r Date <br /> Pleas check heck ApplicableiCategory (1-7) and Fill in the Required Information y � xG <br /> 1:�❑ PUMPER,VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> nor July 1, June 30, 19 - -Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. I .-,CAL. License Renewal No. . <br /> Capacity Gal.,.Weights4-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 E ` <br /> R.S. or R.C.E. Name_ ... R.S. or R.C.E. No. ) --1 .. I�'► <br /> Test Location ; Test Date/Time <br /> 4., 0 SANITATION PERMIT <br /> Job Addr s/Location <br /> c <br /> Owner Address- <br /> 1:1 <br /> ddress❑ SEPTIC TANK t ❑CESSPOOL 'LEACHING FIELD SEEPAGE PIT i❑ PACKAGE PLANT t. <br /> ❑ PERMANENT ❑ TEMPORARY ❑ANEW REPAIR i ❑ OTHER °V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 #�� <br /> Type Construction Disposal Site <br /> Equi <br /> No. of Units pment Storage/Cleaning Location(s) <br /> _ _ x <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 'T� <br /> Operator Name Where Certified` <br /> Plant Location <br /> Plant Capacity No.rUnits Served r) <br /> '7;LLAUNDRY ' For July 1, -June 30, 19 <br /> SIZE : ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. x <br /> � i I hereby cer have preparthis application nd that the work will be done in accordance with.San Joaquin County <br /> 3 ' <br /> ordinances,.state ate_IM ws rules a �gulati d s f t e an Jo quin'Local Health District. <br /> _ -. _ . <br /> A'PPLICANT'S SIGNATURE X oz <br /> FOR DEPARTMENT USE ONLY #- <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT CKPER.SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July-31 <br /> BILLING REMITTANCE $ REMIT } t <br /> BASE EXPLANATION AMOUNT DUE CHECKED . <br /> -- - - ^—tDATE-�^- --W--^-- -DATE REMITTED '�' - "� AMOUNTr,-^1v, <br /> } FEE <br /> LESS <br /> ` PRORATION... <br /> f PLUS <br /> PENALTY --------------- <br /> , <br /> OTHER 4 ` .Y A <br /> OTHER � _ .,�--.,,.�_ .�.� I�,4-7�...�y.�.,gr—G+.../. <br /> Received by D to IU Receipt No. Permit No,- Issuance Date -•-,Mailed v DeOver d I <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ~1601 E.HAZELTON AVE.,P.O.Bo:2009 STOC TON,CA2201 <br /> ' CR'J <br />