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APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon busines the j rrisgictlonal area of th San Joaquin Local ealth District <br /> r Business Name (DBA) �- W �="" " 'zz Address <br /> 3,5 zOwnel tiosI R CIS PI , IAddress <br /> 4 <br /> Firm Partners, Addresses an T Ieephone Numbers (� <br /> It. Business Telephone No. 5 G' Emergency Telephone No. <br /> Contractor Licence No. Date <br /> Applicants Name (Print) i r= ;= W RLQ FA R( <br /> Tltle <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) w <br /> For July 1, June 30, 19 Disposal Sites <br /> ' Description(Make/Yr.,Color) <br /> S _CAL.License Renewal No. <br /> Serial No. CAL. License 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 Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PER T <br /> Job Address/Location <br /> Owner Address <br /> )�. �'—gyp`` 1 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 `• <br /> Type Construction Disposal Site <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 \ <br /> Where Certified <br /> Operator Name <br /> Plant Location t <br /> No. Units Served <br /> Plant Capacity <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 cern that I have prepared this app to on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state ,and rules:fift'L reg lati s the S Joaquin Local Health District. <br /> APPLICANT'S SIGNAT <br /> / qZ <br /> f FOR DEPARTMENT USE ONLYI <br /> t� 0j <br /> - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ly PER SITE ❑ EACH �- Jan ry 1 A .ecaived By January 31 ❑ July 1 &Received BNtyl July 31 <br /> RE <br /> BASE EXPLANATION BILLING fl $ AMOUNT OUE CHECKED <br /> DATE DATE, REMITTED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fleceive <br /> ate Receipt No. Permit No, Issuance Date PMaReceived[M Da I ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAEELTON AVE., .O.Boa2008 STOC N, <br /> CA <br />