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Applications Will Be Processed When Submitted Properly Completed. tiesure toatyia 4d <br /> APPLICATION <br /> t' (For Non-Transferable, Revocable,and Suspendable) - SEPTAGE <br /> V ENVIRONMENTAL HEALTH PERMIT <br /> V LIQUID WASTE <br /> Applicati�isre y m e to r on busl ss in the jurisdictional area of the San.Joaquin Local Health District <br /> HBusiness Name (DBA) Address w, <br /> a Owner :. Address <br /> .,..,.. <br /> Firm Partners, Addresses and Telephone Numbers od <br /> CL Business Telephone No. Emergency Telephone No. <br /> -J Contractor Licence No. <br /> .,�"i �j�lL f� V Title, <br /> Date <br /> Applicants Name (Print) „ . `" ' ' <br /> Please check Applicable Category.(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> - pis asal Sites <br /> For July 1, June 30,19 ` _ —' p <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No.Capacity CAL. License Renewal No. <br /> Gal„-Weights-&-Measures No--•�;: _�_ � __.._ - <br /> Equipment Parking Address ' � •.�` 4 + <br /> i 2. ❑ PUMPER'YARD ... <br /> For July 1, ' June 34, 19 g ; <br /> No. of Vehicles Stored t ! <br /> No. of Chemical*Toilets Stored i t <br /> 3. ❑ PERCOLATION TEST- + <br /> F <br /> ' R.S. or R.C.E.No. ` <br /> R.S. or R.C.E. Name ) z t <br /> Test Location ) } Test Date/Sime I <br /> z , 5 <br /> f _ t <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locatio <br /> Owner Address - ) <br /> 1:1 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD EPAGE PIT ❑ PACKAGE LANT �- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> l 5. [1CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleani kg Location(s) <br /> E <br /> € 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 I ; <br /> Operator Name ) Where Certified ; <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY -For July 1,-June 30, 19 <br /> e <br /> SIZE: 13 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq" Ft. ^' *> <br /> ❑ DRY CLEANING, Chemicals_Osed/Amount/Mo. <br /> ---------------------- - <br /> .. �.� <br /> 1 .4 t <br /> F certify that I•haveprepared this application and that the work will be done in accordanCewith SaJoaquin County - <br /> I hereby ce y - <br /> ordinances, state laws; and rules�ndulati sof the San Joaquin Local Health District. <br /> t <br /> APPLICANT'S SIGNATURE X + I" <br /> .f. FOR DEPARTMENT USE ONLY <br /> r. <br /> Fee is Due• ❑ ANNUALLY ❑ PER UNIT_ _❑ PER_SITE +0 EACH ❑ Janua_ry 1 &Received By January 31 (� July 1 Received By my 31 <br /> L.. "-,; -- - _� _ _ - - - REMIT. <br /> BILL G - EMITTANCE $ AMOUNT DUE CHECKED <br /> ' ..f <br /> BASE. EXPLANATION <br /> D DATE REMITTED "' AMOUNT <br /> 4 t <br /> 3 <br /> FEE. <br /> LESS { €. <br /> PRORATION t f.. <br /> 2 <br /> PLUS 1 } 1 r <br /> PENALTY- <br /> OTHER <br /> OTHER '133* 3 "' ` a <br /> Received by Date Receipt No� Permit No. 1 uance Date Mailed Delivered <br /> 1601 E.HAZEITON AVE.,P.D.Box 2009 S70CKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />