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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication i t x <br /> ! APP_MATibN v 4 <br /> 1 r <br /> �; (For Non-Transferable;Reliocable,'and Suspendable) " ' t• �'SEPTAGE r <br /> ENVIRONMENTAL HEALTH PERMIT t �_ �. <br /> LIQUID WASTE ; } <br /> Application is hereby made to carry on business in the•jurisdictional area.of-the San Joaquin Local Health District- <br /> wBusiness Name (DBA) �, Address <br /> z Owner- Address _ <br /> J Firm Partners, Addresses and <br /> ,yTelephone Numbers <br /> a BusinessTelephoneNo. �"- aET� -. "` Emergency Telephonee-No-1 ti <br /> Contractor Licence No. <br /> Applicants Name (Print). �T��'(` --° �t� Title Date <br /> Please check Applicable Category,(1-7).and Fill in the Required Information- , ;,;; ; . �.a;d•�� It E.. ;� },,;a:v <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t For July 1, - June 30,=19= -` -- "—Disposal-Sites- <br /> - <br /> Description(Make/Yr., Color) <br /> f Serial No. CAL. License No. CAL. License Renewal No. ' " <br /> Capacity? Gal.,Weights &Measures No. i <br /> Equipment Parking Address <br /> #•2.�❑ PUMPER YARD t <br /> For,July 1, June 30,-19 <br /> No. of Vehicles Stored <br /> I <br /> IND. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST g. k <br /> RL.S. or R.C.E. Name _ r R.S. or R.C.E. No. �s <br /> ' y.. <br /> Test Location ;� Test Date/lime <br /> ' 4. I� SANITATION PERMIT ,- <br /> Job�Address/Location )3W , <br /> Owner, Address S <br /> .SEPTIC TANK ❑ CESSPOOL 2LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLIANT <br /> PERMANENT ❑ TEMPORARY 8 NEW ❑ REPAIR ❑ OTHER � <br /> 'S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 k y lk <br /> Type Construction '` ' Disposal Site y - <br /> No of Units _ Equipment Storage/Cleaning Location(s)V. <br /> 1 t ) <br />" 6. ❑ PACKAGE TREATMENT PLANT For July <br /> 1, -June 30, 19 # � <br /> I Operator Name `1 WhereCertified # <br /> I Plant Location <br /> Plant Capacity No. Units Served r, ?- <br /> 7.,r'11 LAUNDRY- For:July 1,-June 30,--19 <br /> SIZE: t~❑ Less Than 1,0,00.S9. Ft., © More Than 1,000 Sq. Ft. <br /> € ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 } <br /> IF 1 <br /> e <br /> I e' I hereby certify that I h prepared this application a hat the w( 1 ilj„be done in accordahce with San Joaquin County <br /> ordinances, state law n tions of th n Joaquin al Health District- , <br /> APPLICANT'S SIGNATURE X <br /> Nif �y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑_'ANNUALLY ❑ PER UNIT` ❑ P_ER SITE ❑ EACH_ ❑ January 1 &Received B.ty_Jan7uary 31: ;❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> :BASE EXPLANATION ' BILLING ( REMITTANCE - s �^ A OUNT DUE CHECKED <br /> DATE 'DATE - REMITTED .,fin AMOU <br /> ° FEE ' > i :aft <br /> LESS 'L x <br /> PRORATION <br /> PLUS i> <br /> PENALTY r <br /> OTHER - - - ._ - + i S` a.�. f'4 _ <br /> OTHER - - :a ;>: - j i• - <br /> Received by Date ,Receipt No. Permit No. 1 Issuance Date Mailed Delivered <br /> APPLET <br /> ICANT—RURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEf1MITlSERVICES 1601 E.H LTONN ZE P.O.Box 2009 SST�OCKTON,_CA 95201 <br /> o , <br />