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Properly Applications Will Be Processed When Sub AmPPLICATIONpieteBe u <br /> re 10Z1911 I1TV <br /> (For Nan-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> en JoaquinI Heat District <br /> buessintheLunsdictional area of th6 <br /> ' here ydetocaro ' -iAr.- V <br /> Application <br /> mBusiness Name (DBA) Address <br /> a Owner <br /> Firm Partners, Addresses and Telephone�umbers Emergency Telephone No. <br /> aBusiness Telephone No. �_31-f 3 � �� •-� <br /> Contractor Licence No. Title EST Date <br /> Applicants Name (Print) <br /> 'J. - o I. <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, <br /> June 30, 19 Disposal Sites + <br /> Description(Make/Yr., Color) CAL, License No. GAL. License Renewal No. <br /> Serial No. <br /> Gal.,Weights 8, 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.C.E. Name Test Date/Time <br /> Test ocation <br /> t q, F SANITATION PERMIT 77 <br /> f Job Address/ ocation Address <br /> I Owner 13 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC ANK ❑ CESSPOOL ❑ NEW �REPAIR El OTHER <br /> 11 PERMANENT IJ TEMPORARY <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units . Equipment Storage/Cleaning Location(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name 1 <br /> Plant Location No. Units Served <br /> t Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> k SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, <br /> and <br /> frules <br /> re tions of the San Joaquin Local Health District. <br /> t APPLICANT'S SIGNATURE X ` <br /> if <br /> i FOR DEPARTMENT USE ONLY <br /> k <br /> ed By <br /> 31 <br /> 4 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE [I EACH REM�TANCEry' &ReceivedREMIT <br /> AMOUNT <br /> By January 31OT DUE &Recei�HECKEDy <br /> F BILLING <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> r <br /> g <br /> FEE b <br /> LESS 1 <br /> PRORATION <br /> I PLUS p <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I T� eliver d e <br /> 4 - Receipt No. Permit No. <br /> suance Date Mailed <br /> Received by Date 1601 E.HAZELTON AVE.,P.O..Box 2009 STOC ON.CA'95201 <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />