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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheAppllcauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the an Joaquin Local Health District <br /> N Business'Name (DBA) PaiePrS�t - 1S ,T�2< Address <br /> F r - Address <br /> z Owner <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. W,245.— 9C,20-3 Emergency Telephone No. <br /> a <br /> � Contractor Licence No. Z"5 — S43 <br /> Applicants Name (Print) t- t Title Date 'I <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 /> r 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.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> k - <br /> ( 4. 2-SANITATION PERMIT <br /> Job Address/Location ' 0 <br /> Owner *56411-1+ !�'342.FPP S Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 19--LEACHING FIELD DISEEPAGE PIT ❑ PACKAGE PLANT <br /> & ERMANENT ❑ TEMPORARY ❑ NEW " a-ITEPAIR ❑ OTHER <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 D <br /> Type Construction Disposal-Site a <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 36L;19 <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. Y <br /> � y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t ordinances, state laws, a rules and re lations of San uinkocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> CW" <br /> Fee 1S DUB: ❑ ANNUALLY ❑'PER UNIT"� E1-PER SITE` EA ❑"JOriiiary 1$Recewed By'Jaivary 3i' �] July-1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> E r _ <br /> C FEE i 1 <br /> 4 _ S <br /> LESS <br /> PRORATION <br /> PLUS <br /> k PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Oate Receipt No. Permit N0. - ssua ce Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTO .,'P.O.Box 2004 STOCKTON,CA 95201 <br /> r' <br />