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T r 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<PERMI <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Laical Health District <br /> NBusiness Name (DBA) Address <br /> i Owner Address t <br /> Q <br /> J Firm Partners, Addresses and Telephone Numbers <br /> W6, <br /> CL a -3 Emergency Telephone No. <br /> CL Business Telephone No. —� <br /> Contractor Licence No. �. <br /> L Applicants Name (Print)4S -t�Al L. (� 'c�11� Title C_ Date <br /> �} �L <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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. .9 SANITATION PERMIT <br /> Job Addre s/Location 1 i <br /> tAS <br /> IE <br /> Owwner <br /> b� Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT- -❑ PACKAGE PLANT Ilk— <br /> E] <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ��VO�f p <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 11— 7 c) --tt <br /> h <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 v <br /> SIZE: C1,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 pre <br /> thi plication anis that the work will be,done in accorda e w ry aquin County <br /> ordinances, state laws, and rules lations San'Jo Q ocal Heilth District`' �/� <br /> APPLICANT'S SIGNATURE X f 2 1[ )• - <br /> -IFOR DEPARTMENT USE ONLY` <br /> j - - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PE_R.SITE ❑ EAGH ❑ January 1 &Received By January 31 ❑ July'1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE-- AMOUNTDUE. CHECKED <br /> DATE DATE REMITTED, AMOUNT <br /> 4 <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER - <br /> OTHER <br /> fag �J <br /> Received by Date Receipt No. Permit o. Issua ce D Iftled���Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.;P.O.Boe 24D9'"""STO KCA1 <br /> � ( 9 <br />