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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPL1CAtION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> s} SEPTAGE <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> c3� LIQUID WASTE <br /> Application' er by m e to r on business' hg jurisdictional area of the San Joaquin Local Heat DI rirlct <br /> m ousiness Name(DBA) /!�� Address1�65y <br /> aOwner �� 'i L Address <br /> Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) Title S - Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information cz <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) p <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> CAL. License No. CAL. License Renewal No. ' <br /> Serial No. � d <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 R <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. C-SANITATION PERMIT f <br /> Job Address/Location �+ /7 <br /> �t?G Address - <br /> Owner ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT I <br /> 44-PERMANENT ❑ TEMPORARY 9NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 !� <br /> ype Construction Disposal Site -� <br /> No.of Units Equipment Storage/Cleaning Location(s)_ ) <br /> .r <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 /> T. 11 LAUNDRY For July 1,-June 30, 19 <br /> SIZE: O Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I <br /> i` <br /> 1 hereby certify that 1 have pr ared this a cation and that the work will be done in accordance with San Joaquin County &. <br /> ordinances,state laws,a re a s of the San aquin cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> ar <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑July I&Received BylTuly 31 � <br /> C BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> us s` <br /> • FEE '� � <br /> LESS <br /> PRORATION <br /> �l PLUS <br /> PENALTY <br /> OTHER <br /> _ a <br /> t OTHER <br /> 1 _ <br /> bICT r <br /> i Received by Date Receipt No. Permit No. I sua a Date iled Deli <br /> APPLICANT—RETURN ALt COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1trD1 E.14A2ELTON A Boa�� <br /> STOCK N.CA 520 <br /> 1 <br /> I <br />