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.. ...a.. -.-, <br /> Applications Wkkl Ee Processed When SubAPPLICATION - • <br /> (For Non-Transferable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH_PERMIT <br />` r A LIQUID WASTE <br /> Application is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> y Business Name (DBA) gddress i <br /> L v: <br /> a Owner <br /> Firm Partners, Addresses and Telephone Numbers 41 "s , Emergency Telephone No._ <br /> aBusiness Telephone No: <br /> Contractor Licence No. Title. 4 ' Date. <br /> . <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7)and Fl1k in the Required,lnformation,:., � 1, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 Disposal Sites - <br /> For July 1, . <br /> Description(Make/Yr., Color) CAL. License Renewal No. . <br /> Serial No. GAL. License No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Tdilets'Stored <br /> 3. ❑ PERCOLATION TESTtip <br /> " ' <br /> �'• �,*� i���x .-if'R.S.or R.C.E. No. <br /> R.S. or R.C.E.Name <1 F; Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Logation �4 / G <br /> Address <br /> Owner' <br /> SEPTIC TANK ❑ CESSPOOL �EACHING FIELD ❑ SEEPAGE PIT`"'�-PACKAGE PLA <br /> ❑ NEW 11 REP <br /> ❑ OTHER ..,_;. », r; <br /> ❑ PERMANENT ❑ TEMPORARY_ . <br /> I 5. ❑ .CHEMICAL TOILETS For July 1. -_-June 30, 19 I <br /> i <br /> Type Construction ~' i A. Disposal Site ; <br /> No. of Units Equipment Storage <br /> No. <br /> Location(s) <br /> f <br /> S. ❑,PACKAGE TREATMENT PLANT For July 1, June 30, 19 Where Certified __�_-' <br /> .'Operator Name ` <br /> Plant Location Served <br /> No. Units <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. f L� ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 I <br /> 1 I hereby certify that I have prepared this application and that ffie worKwilk be done in accordance with-San Joaquin County <br /> I ordinances,state laws, and rules and gulati s of the San Joaquin Local Health District. j J �� _Atr <br /> ( ; r 5" i `tel v <br /> APPLICANT'S SIGNATURE X +1 ) <br /> I Y <br /> t '< T._FOR DEPARTMENT USE ONLY I 1 <br /> aF t s t❑ Jul 1 &Received By July 31 <br /> Fee is Due: ❑ ANNUALLY PER UNIT #❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 3 s y REMIT <br /> BILLING s REMITTANCE e : '__AMOUNT DUE. <br /> I- BASE EXPCANATION� ---PATE `_—'DATE" _' "_i-REMITTED_t � * AMOUNT <br /> CHECKED <br /> - <br /> FEE <br /> i LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> d M,+..*�,w�m�a•�•p..:s xr...-��w., --w.mow,.. ,.�..L'�:,� <br /> OTHER ' <br /> ' Date 4ssu nce Da Mailed Delivered <br /> Receipt No. Permit No. <br /> Received by � 1501 E.HA ELTON AVE.,P.O.Bax 2009 57DCK70N,CA$5201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />