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� Y Applications Will Be Processed When Sub�m'itiPeL'CAT�ONp e <br /> P <br /> .(For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTIAo WASTE <br /> HEALTH PERMIT <br /> Ll Q <br /> I Health Strict <br /> Applicati ,(ieb�{+�de o carrsmn m t±elu dictionaAdd of <br /> Sthe 5` qu} �� C, YY <br /> y Business N. DBA) _a{ 1CrJ Address <br /> A(Zz Owner lj1 <br /> a <br /> Firm Partners, Addresses an Tele hone Numrs Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Title Date W <br /> L Applicants Name (Print) L! ) <br /> 1-7)and Fill In the Required information <br /> Please check Applicable Category( <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION(FORE EACH <br /> Sites <br /> VEHICLE) <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. Licz:nse Renewal No. <br /> Serial 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 Toilets Stored <br /> 3 ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.G.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT Q ` Z oft] _ <br /> Job Address/Location �`�� ����u ! Cn b <br /> Owner RV f'h�t MA)V Address ❑ PACKAGE PLANT R) <br /> 11 SEPTIC TANK ❑ CESSPOOL C3 LEACHING FIELD C3 SEEPAGE PIT 11 OTHER <br /> ❑ PERMANENT � <br /> ❑ TEMPORARY ❑ NEW REPAIR _ <br /> Disposal Site �0� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �� 11�2 cAb S5k-­ <br /> Type Construction <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 <br /> More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> ' <br /> 11 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> I <br /> � at the work will be done in accordance with San Joaquin County <br /> I hereby certify that l have prepared this application and th <br /> ordinances, state laws, and r and regulatio Joaquin Local Health District. <br /> J: <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> REMIT <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE BILLING <br /> EACH REMITTANCE 1 &Received By January 31 Af�O ❑ DUE &Rece�CH MI ved By JUIY 3i <br /> 6 REM$TTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRDRATION <br /> PLUS <br /> 1 PENALTY <br /> OTHER <br /> OTHER <br /> Permissuance Date Mailed elivere <br /> I � ed by MITlSERYICES <br /> Cby Receipt No. it No.ate. 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKY. N,CA�1 <br /> Receive — <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER <br />