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. . cauvn. <br /> Applications Will Be Processed When Submitted Properly Completed. Be13Sure oSign � <br /> APPLICATION <br /> (Far Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the San Joaquin Local ier�althrDistrict , <br /> OF Business Name (DBA) �® 7 `��0 11110 <br /> 'C ��P41 Address <br /> Address <br /> z Owner we�C-r6K _ <br /> I <br /> J Firm Partners, Addresses and��lepho�Nul�ers Emergency Telephone No. �S 8r�- <br /> aBusiness Telephone No, TT <br /> Contractor Licence No. Title 's Date <br /> Applicants Name(Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> i. ❑ 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 /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br />'i 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> I <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.G.E.No. <br />( R.S. or.R.C.E. Name <br /> Test Date/Time <br /> l Test Location _ <br /> 4, .P4 SANITATION PERMIT FLd.�`� 5 CSC! J <br /> r Job Address/Location / �iC.Q S <br /> Owner L.�-f P S NLV Address h <br /> ❑ CESSPOOL 1:1 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK REPAIR C9 OTHER&104066S6pria Tape <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW -n <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> s Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> k Plant Location <br /> ! No. Units Served <br /> Plant Capacity <br /> E 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE'. ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> 1 ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 rules nd regu` tions f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due-. ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH C) January 1 &Received By January 31 ❑ Ju4y 1 &ReceiveRdEMITBy uVy 31 <br /> r BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> I r Receipt No. p Pel 11 A No. Issuance Date Maile De ivered <br /> k Received by Uate <br /> 1601 E.HAZELTON AVE.,P.OABox 200��OGKTON,CA 95201 <br /> Grill <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES � •� �Q - ! <br /> T i�I <br /> I <br />