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leted tse aurc �.,_.W. <br /> Applications Will Be Processed When Submitted ProQerly Comp <br /> APPLICATION <br /> -(For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL <br /> V"LIQu D W STE TH PERMIT <br /> Uation is hereby made to carry on business in the jurisdictional area of the San Joaqu'm.Local Health District <br /> A*'Uc Address - <br /> � <br /> wBusiness Name (DBA? Address ! <br /> z Ownerr� Y, ,. red Af-'f "` c3' ta <br /> Firm Partners, Addresses and Telephone Num ers Emergency Telephone No- I <br /> aBusiness Telephone No. <br /> �Contractor Licence No. ,� Title Date <br /> 4- <br /> L Applicants Name (Print) <br /> Fill in the Required Information <br /> Please check Applicable Category (1-7)and <br /> 1. [1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 3019 Disposal Sites <br /> i For July 1, June , i <br /> j Description(Make/Yr., Color) CAL. License Renewal No. <br /> CAL. License No. <br /> Serial No, <br /> Gal.,Weights &Measures No. <br /> Capacity " <br /> Equipment Parking Address <br /> y. ❑ PUMPER YARD y <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST ` <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> I. Test Location • ` <br /> 4. ❑ SANITATION PE I. T LJ Ii 11; t ` <br /> Job Address/Location ty� Address <br /> Owner 11 .LEACHING FIELD 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL 11 OTHER (- <br /> 11 PERMANENT D .TEMPORARY '-19,NFW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site <br /> Type Construction <br /> Equipment Storage/Gleaning Locatio <br /> No. of Units ns) <br /> r B, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> f Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity N -•, , <br /> f 7, ❑ LAUNDRY For July 1, June 30;19 l <br /> { ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> SIZE: ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> b ycred this application and that the work will be done in accordance with San Joaquin County <br /> t I herebertify that I, have <br /> ordinances, state laws, and <br /> s And regulations _ e San Joaquin Local Health District. <br /> i APPLICANT'S SIGNATURE X. <. <br /> FOR DEPARTMENT USE ONLY <br /> Su4 1 &Received By July 31 <br /> EACH ❑ <br /> ❑ January 1 &Received By January 31 ❑ Y <br /> REMIT <br /> Fee Is Due:-❑ ANNUALLY: REMITTANCE <br /> UNIT © PER SITE REMITTANCE $ AMOUNT DUE CHECKED <br /> _ BILLING REMITTED <br /> AMOUNT <br /> " - BASE EXPLANATION DATE DATE - <br /> FEE <br /> } LESS 1r flJ <br /> PRORATION of <br /> k PLUS <br /> ` PENALTY f <br /> L. <br /> OTHER <br /> OTHER <br /> Issuance Date ~Mailed Delivered. <br /> _ Receipt No. 41::: Permit No. <br /> Received by - - Date t601 E.MAZELTON AVE.,,P.O. E09 . STOCi(/O�'CA 95201. <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. '0417//p/o%�_'^^ <br /> t .. - <br />