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Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign The Application. li C 1 <br /> ;r APPLICATION <br /> (F )n-Transferable, Revocable,and Suapendable. SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQg10 WASTE <br /> Application i hereby made to carry on business in the jurisdictional area of the Sen Joaquin Local Health District <br /> IDEA)�� —,i iy Address <br /> �+ Business Name DBA —r-- <br /> �Z Owner 4 •,4 Address _ <br /> i <br /> Firm Partners, Addresses and Telephone m ers _ <br /> a Business Telephone No. Emergency Telephone No. <br /> t ; <br /> Contractor Licence NO: ' <br /> Applicants Name (Print). - /U Title �?`--�� Date <br /> Please check Applicable Category(1-7) and Fill_In the Required Information 1 <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 Gel., Weights & Measures No. <br /> r <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> t� <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. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> El PERMIT <br /> Job Address/Location L r� -� 12— <br /> Owner Address � F � <br /> EPTIC TANK ❑ CESSPOOL ��C ACHING FIELD ❑ SEEPAGE PIT. 11 PACKAGE PLANT <br /> 13 PERMANENT ❑ TEMPORARY ❑ 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 rh <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 the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and repulations of th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X K <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY •❑ PER UNIT ❑ PER SITE EACH ❑ uery 1 d Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMI ANCE S AMOUNT DUE CHECKED <br /> ry DATE DATE REMITTED AMOUNT <br /> FEE 3 <br /> LESS ; <br /> PRORATION i <br /> PLUS <br /> PENALTY J, <br /> //. <br /> OTHER r1 <br /> OTHER <br /> dR�ly ► lag l,2 � ?DlierwdReceived by Date Receipt No. Permit No. Iwu nee ate Maned 10,70—APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 1 E.HAZELTON AVE.,P.O.Boa 20d9 CKTON,CA Y5201 <br />