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�— P Y • <br /> Applications Will Be Processed When Submitted Pro erl. Completed:e _ <br /> APPLICATION ` >; <br /> (Far Non-Transferable, Revocable, and Suspendatile)� <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> Application' ere m to carryon usiness i the junsdi tionalarea Of Addressth an J�oaqui`Loll Health D `trict <br /> wBusiness Name (DBA) Address 4 <br /> z Owner _ i <br /> a <br /> J Firm Partners, Addresses and Telephone umbers Emergency Telephone No: . <br /> a. Business.Telephone No. ('5; ] <br /> 1`Contractor Licence No. Title r Date 1 <br /> 1 <br /> Applicants Name(Print) A <br /> Please check Applicable Category (1-7) and Fill in the Required Information Pss "l <br /> [3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) j <br /> 1 - Disposal Sites N <br /> For July 1, 4 June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL_License Renewal Na. ' <br /> ;• <br /> Serial No. <br /> Gal., Weights &Measures No. <br /> Capacity , <br /> Equipment Parking Address <br /> ri( 2, ❑ PUMPER YARD <br /> E For July 1, June 30, 19 <br /> 1kNo. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 1 3, ❑ PERCOLATION:TEST R.S.or R.C.E. No. <br /> R.S.or R.C.E. Name Test Date/Time <br /> Test ocation r <br /> 4. PQ SANITATION PERMIT <br /> F Job Addr Location Address <br /> Owner LEACHING FIELD SEEPAGE P1T ❑ PACKA E PLANT <br /> I SEPTIC TANK ❑ CESSPOOL �( 11 REPAIR <br /> 13 OTHER <br /> PERMANENT <br /> ❑ TEMPORARY }� NEW - <br /> � y <br /> 5. 13 CHEMICAL TO For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> • Equipment Storage/Cleaning Location(s) <br /> No. of Units + <br /> g. <br /> C] PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> l' Operator Name <br /> I Plant Location <br /> pp No: Units Served <br /> I" Plant Capacity <br /> 7.-".[] LAUNDRY For July 1, -June 30, 19 <br /> SIZE'. ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k I hereby certify that 1 have prepared this application and thatahuIaccordance with San Joaquin County <br /> in Local Health District F <br /> ordinances, state laws, an rules and r ulati the q <br /> K <br /> � APPLICANT'S SIGNATURE X <br /> ' FOR DEPARTMENT USE ONLY <br /> 1 & ceiv Sanuary 31 ❑ Su4y 1 &Received 8y July 31 <br /> t REMIT <br /> t PER SITE ❑ EACH Sanuary <br /> Fee IS Due: ❑' ANNUALLY ❑ PER UNIT REMITTANCE $ R OUNT DISE CHECKED <br /> _ BILLING <br /> BASE EXPLANATION DATE DATE R ITT D AMOUNT <br /> 1 <br /> FEE S r <br /> LESS <br /> `_._. PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance Date Mailed /De4ivere <br /> Receipt <br /> No IT/SERVIPermit No.CES ,. CA 95 91 <br /> Received by Date - 1601 E.11AZELTON AVE.,P.O.Box 2009 STOCIC�ON, <br /> ' -pPPL1CANT—RETDRN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMr 1 <br />