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�... -- <br /> ppplicatipns Will Be Processed When SuAPPpL�Cpi,T�ONe eBe , <br /> (Far Non-Transterable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h rebmad to carryyan business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> wBusiness Name {DBA} kv Address <br /> i Owner <br /> 4 <br /> u Firm Partners, Addresses and Telephone Nombers Emergency Telephone No. - <br /> a Business Teiephone.No. � � b� - <br /> 4 <br /> Contractor Licence No. Title " ; Date 1 <br /> L Applicants Name(Print) <br /> 7 and Fill in the Required Information ar} .�, �s. 03 <br /> Please check Applicable Category(1- ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites. <br /> •For'July 1,' June 30, 19 ,,, <br /> Description(Make/Yr., Color) CAL. License Renewal No, <br /> Serial No. CAL. License Nii. <br /> Capacity Gal.,Weights &Measures No.t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 — <br /> No. <br /> 9 No. of Vehicles Stored <br /> No. of Chemical Toilets StoredOr <br /> 3, ❑ PERCOLATION TESTS i. R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name Test Date/Time <br /> d <br /> Test Location. <br /> q. ❑ SANITATION PERMIT <br /> F <br /> t Job Address/Location <br /> Owners Address <br /> ❑ LEACHING FIELD'" ❑ S PAGE PIT ❑ PACKAGE PLANT O <br /> ❑ SEPTIC TANK ❑ CESSPOOL REPgIR 13 OTHER //y•y <br /> I' ❑ PERMANENT ❑ TEMPORARY:' ❑ NEW '- <br /> I 7'June 30,•19 <br /> 1 5. ❑ CHEMICAL TOILETS For_July,r.,,_ <br /> Type Construction <br /> _ Disposal.Site <br /> Units Equipment Storage/Cleaning Location(s) <br /> No.of <br /> 6. Q PACKAGE TREATMENT PLANT For July i, -Jgne 30,.19 <br /> a. Where Certified <br /> Operator,Name ! <br /> 4 r, <br /> Plant Location 4 i.4 r ; ! <br /> �"� No. Units Servedrr <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19— <br /> SIZE: <br /> 9 _SIZE: ❑ Less Than 1,000 Sq. Ft,,,Y D,More Tha 600.5q..Ft � <br /> ❑ DRY CLEANING, Chemicals Used/Amount/iulo. will- <br /> b <br /> I hereby certify that`I`have prepare d-tfiis application and that the work be done in"accordance with San Joaquin County <br /> ordinances, state laws, 0—d--rulesandr ulations of t e San Joaquin Local Health District. <br /> } APPLICANT'S 51GNATURE X ` �- <br /> e r - <br /> h FOR DEPARTMENT USE ONLY <br /> January❑ 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH h REMIT. <br /> i UE: CHECKED <br /> BILLING REMITTANCE $ AMOUNT D <br /> BASE EXPLANATION DATE DATE ,{ REMITTED AMOUNT <br /> q s <br /> FE �f <br /> LESS <br /> PRORATION _ <br /> PLUS t <br /> PENALTY - <br /> - v <br /> OTI�ER. 1 <br /> OTHER <br /> ~ I suance ate Mailed Delivered <br /> Date Receipt No- Permit No. <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 S70CKTON,CA 95201' <br /> +- APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI5ERVICES <br />