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Applications Will Se Processed When Submitted Properly Completed. Ue Sure iosign Fir•+Yr•• ' <br /> i)e APPLICATION <br /> d` I (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> e to a on b ess in the jurisdictional area of the S�4o S uin��al Health D1stri t <br /> I <br /> y ApplicaWfio &h ,eby',: dBusiness N e (DBA) Address <br /> z Owner,_T d Address <br /> : Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a. Business Telephone No. <br /> Contractor Licence No. Title f S Date F <br /> Applicants Name (Print) j <br /> � <br /> Please check Applicable Category 6 <br /> 6-7}and Fill in the Required Information ^� <br /> 1. El PUMPER VEHICLE PERMIT REGISTRATION (FOR EAGH VEHICLE) Vv <br /> For July 1, June 30, 19 IM Disposal Sites <br /> Description(Make/Yr.,Color) IM CAL. License Renewal No. <br /> Serial No. IM° CAL. License No. <br /> Capacity IM Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July I, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I� s <br /> 3, ❑ PERCOLATION TEST R,S. or R.C.E. No. ¢ <br /> R.S. or R.C.E. Name -- <br /> IM ' ' 'w Test Date/Time <br /> Test Location VV <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loation <br /> Owner Address J ❑ ACKAGE PLANT <br /> p! LEACHING FIELD ❑ SEEPAGE PIT <br /> X—SEPTIC TANK C1 CESSPOOL 13 REPAIR <br /> A:5-OTHER <br /> PERMANENT 13 TEMPO RfAfRY A NEW <br /> 5. ❑ CHEMICAL TOILETS Forl�July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units ,I1. Equipment Storage/Cleaning Location(s) <br /> k 6. ❑ PACKAGE TREATMENT PIM ANT For July 1, -June 30, 19 Where Certified <br />! Operator Name <br /> Plant Location I`I _ <br /> II No. Units Served <br /> Plant Capacity <br /> 7. El LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq.' t., ❑ More Than 1,000 Sq. Ft.. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 hereby certify that I'have prepared this a ' tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and es nd ation of the San Joa Loca Health District. `o <br /> APPLICANT'S SIGNATURE X I' <br /> QLk .CA r f <br /> j FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT PER SITE EACH ❑ January 1 &Rece vie J }ary 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY ��i REMIT <br /> IM' BILLING REMITTANCi AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE ITTED AMOUNT <br /> FEE IM <br /> LESS it <br /> PRORATION III <br /> + I� <br /> PLUS I <br /> PENALTY <br /> rl OTHER <br /> OTHER <br /> 1 II ( B� 1� y$� r�SD <br /> II <br /> I suance ate ailed Delivered <br /> Permit NoReceipt No. Per , <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK70N;GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />