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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - } <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is" ereby made to carry on business in the jurisdictional area of-the San Joaquin Local Health District 4 <br /> yBusiness Name (DBA) V- Address <br /> z Owner Ala 9/x ? Address <br /> J Firm Partners, Addresses and Telep one Numbers /L � <br /> CL <br /> IL Business Telephone No. �� Emergency Telephone No. I <br /> Contractor Licence No. IV <br /> L Applicants Name (Print) 2s z bcy a Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) M <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> a <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 h <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. a SANITATION PERMIT A <br /> Job Address/Location P OA <br /> Owner Address !� <br /> K SEPTIC TA K ❑ CESSPOO � LEACHING FIELD " ❑ SEEPAGE PIT ❑ PACKAGE PLANT..f `i <br /> PERMANENT ❑ TEMPORARY E�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 /> r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name _ <br /> Plant Location <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. Y <br /> I hereby certify that I have prepared thisapplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaqui" Loca Health District. <br /> APPLICANT'S SIGNATURE X <br /> -�.. i <br /> # <br /> f _ FOR DEPARTMENT USE ONLY- <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July i &Received By July 31 <br /> 5 REMIT <br /> BASE• EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S o� S2 t �N q ,S 77 4S O <br /> s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> s- <br /> 111:s(79 7A StS'1-3 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: _ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Bo.x 2008 STOC.KTON;CA 95251 l <br />