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... <br /> ,r , .... <br />� --- ��Applications Will Be Processed When Submitted Properly Completed. BeSure <br /> APPLICATION <br /> (For Non-Transterabte, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> !k LIQUID WASTE <br /> ! Application is h by made to rr on business in the jun ctional area of the S��oa Local Health District <br /> �— Address <br /> wBusiness N e (DBA) Address U <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbe Emergency Telephone No. <br /> CL <br /> Business Telephone No. �G�- '�� <br /> Contractor Licence No. / Title Date_ <br /> Applicants Name (Fyint) <br /> Please oheck_Applicablle Category (1-7) and FilI in the Requir d'information <br /> 1. [1PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For';lu`ly 1,`�A June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> j Serial tJo. CAL. License No. <br /> *.#,r1 =k E Gal.,Weights & Measures No. <br /> Capacity . <br /> Equipment Park ng Address � - <br /> 2. ❑ PUMPER YARD <br /> For July�1-, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> j. R.S. or R.C.E. Name # 4 . Test Date/Time <br /> Test Location <br /> I 4. ❑ SANITATION PERMIT r . <br /> I Job Address/L ation <br /> Address <br /> El PACKAGE PLANT <br /> Lf SEPTIC TANK EI CESSPOOL. <br /> LEACHING FIELD AGE PIT 11 OTHER C <br /> 13 PERMANENT 1:1 TEMPORARY <br /> ❑ NEW REPAIR s <br /> 5. 0 CHEMICAL TOILETS For July 1, June 30, 19 j <br /> Type Construction <br /> Disposal Site C <br /> No. of Units .Equipment Storage/Cleaning Locations) <br /> s .k <br /> 6. 11PACKAGE TREATMENT PLANT' For July 1, -June 30, 19 # Where Certified <br /> i >'', 1 <br /> Operator Name I WI F <br /> � <br /> Plant Location '"�""'"°'"'"" -' No. Units Served <br /> Plant Capacity <br /> 7. 13 LAUNDRY For July 1, -June.30,.19" <br /> SIZE: 13 Less Than 1,000 Sq.'F..,.?jjC3 rMore Than 1,000 Sq. Ft. <br /> 13 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I <br /> I hereby certify that I have prepared this application and that the work will done in accordance with San Joaquin County <br /> Healordinances, state laws, and rules and r lations of the San uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> ` FOR DEPARTMENT USE ONLY <br /> r Fee Is Due: ElANNUALLY ❑ PER UNIT '121PER SITE EIEACH ElJanuary 1 &Received By January 31 ❑ July 1 &.Receiv REMITBy uly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> i <br /> FEE <br /> LESS <br /> y. PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> Date <br /> Permit No. ssuanc Date Mailed De fiver <br /> Received by Receipt No. <br /> APPLICANT-RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT!- SERVICES E• 1ELT�F!'YE+P 8oi 2009'- STOCt4 ON,CA 5201 <br />