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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> I APPLICATION C� <br /> (For Non-Transferable, Revocable, and Suspendablie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> i Owner _ M 0 A F_' - Address _. r � <br /> I ..— <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br />( Contractor Licence No. <br /> t Applicants Name (Print) C �- Title ������� Date <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 /> j Serial No. ; CAL. License No. CAL. License Renewal No. <br /> r Capacity �� Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,,-- June 30, 19 <br /> i <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 /> l 4. ❑ SANITATION PERMIT <br /> Job Address/Location 4 9 ed+ ® <br /> I <br /> Owner Q fi+- [r _ Add ess <br /> r. <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 /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> j 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 /> f f <br /> I hereby certify that l have prepared-this application-and•that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and gulations oLtLe Sanquip Local,Health district. <br /> APPLICANT'S SIGNATURE X ~ <br /> j t <br /> ° 1 FOR DEPARTMENT USE ONLY <br /> (t ► - <br /> Fee Is Due: El ANNUALLY El PER UNITAIJ DS PER SITE 6 ❑.•EACH I❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> (—BILLING»–» REMITTANCE $ REMIT a <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE ATE <br /> Aly— REMITTED <br /> ' AMOUNT <br /> I FEE r , ff If a� <br /> LESS <br /> PRORATION rr " <br /> PLUS E <br /> PENALTY <br /> OTHER <br /> OTHER p <br /> Received by r a Dat Receipt No. Perrnkt No. Issu nce. te. „Mailed a were <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t601 E.HAZELTON AVE.,P.O.Box 2009 STOCKY N,.CA 2 <br />