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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Apprcatlon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ! <br /> LIQUID WASTE <br /> Applicatio I er ma a to car bus n sin thejuri ctional area of the 5ay1 a_yin L�al I�a�th�YD�istric� <br /> Business ��(DBA) �i 1 ��� k�rOe- X Address V <br /> a Owner <br /> —Tim M A ae Address <br /> 0:-Firm Partners, Addresses and lephone Numbers 2 � � <br /> �e Emergency Telepbgne No. i <br /> C6 Business Telephone No.: f <br /> Contractor Licence No. <br /> Applicants Name (Print) 1m �� Title '� � Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <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, t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ <br /> No. of Vehicles Stored S <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST c� <br /> R.S. or R.C.E. Name R.S. or R.C.E. No: : <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 5 <br /> Job Addres oca ion �N I heti Job <br /> Owner a e6 etz- M A..,/ Address <br /> 9VSEPTIC TANK ❑ CESSPOOL 10 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT S <br /> ❑ PERMANENT ❑ TEMPORARY ED NEW ❑ REPAIR ❑ OTHER / <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 <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 t work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regulati ns of San Jo uin Local Health District, <br /> APPLICANT'S SIGNATURE r - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ nuary 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION. BILLING ITTANCE $ AMOUNT DUE CHECKED <br /> DATE /I DATE REMITTED AMOUNT <br /> FEE SGf CI <br /> LESS r <br /> PRORATION' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ©3 3—'7 G <br /> -7 0 `7 © 1 -7-jHTONIA <br /> Received byNO. Permit No. Issuance Date Mailed elivAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 . STOC1 <br />