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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> - i <br /> Applicatio is higreby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> N <br /> Business Name (DBA)�s,_�ts�-- <br /> ey <br /> aOwner �p— asi Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a k <br /> Contractor Licence No. <br /> Applicants Name (Print) Title _ ' �7> 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) CAL. License Renewal No. <br /> - <br /> Serial No. CAL. License No. <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 TES_ T <br /> `R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location *# `Test Date/Time <br /> 4. ;.SANITATION PERMIT <br /> Job Address/Location <br /> Owner A dress 1G <br /> 11 SEPTIC TANK E] CESSPOOL E''LEACHING FIELD. 42-EEPAGE PITJk- El PACKAGE PLANT 1 ^ <br /> PERMANENT ❑ TEMPORARY ❑ NEW ,REPAIR 11 OTHER v , <br /> s. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 C ) <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 /> Where Certified <br /> t Operator Name <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. ^9 <br />` ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i 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 a reg ns of ye San oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 0 <br /> ii FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION t <br /> PLUS / <br /> PENALTY <br /> I' OTHER <br /> OTHER _ Y �O ��JAC> <br /> 'Received by <br /> Date Receipt No. Permit No. Issuance D Mailed Delivered <br /> .APPLICANT—RETURN ALL COPIES TO: ;; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO .,P.D.bow 2004- 5TOCK70N;CA 96201 <br />