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- <br /> Applications Will Be Processed When SuAbmitted ProperlyBe Sure o Ig 1 <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> UQUID WASTE <br /> t <br /> Applicati hereby m�de to a�(y on business in the jurisdictional area of the S�rl$O uin j�oc,1I Head Dt t�riet <br /> 'i. R a 1 , , /(a,- -�'LV_ Address // I,S <br /> w Business NaN%(DBA)_ d <br /> Owner JIM <br /> CARD!/e f I Address <br /> X32 - GSQY <br /> Firm Partners,Addresses and Telephone Numbers Emergency Telephone No. <br /> 0. Business Telephone No. y3g/ <br /> �Contractor Licence No. Title Date <br /> Applicants Name(Print) ' <br /> Please check Applicable Category(1-7)and Fill In the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) -� <br /> For July 1. June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL.Lic-,se Renewal No. f <br /> Serial No. CAL.License No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 1, <br /> No.of Vehicles Stored <br /> No-of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S.Or R.C.E.Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIgL 7fO ,0S5 04/C R p <br /> Job Address/Location <br /> Owner— �'V �' Address - <br /> 19 SEPTIC TANK 1:1 CESSPOOL RL LEACHING FIELD ❑ SEEPAGE PIT . ❑ PACKAGE PLANT 3.. <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW <br /> ❑ REPAIR ❑ OTHER <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 &oo <br /> Type Construction Disposal Site Tcc 3W <br /> No.of Units <br /> Equipment Storage/Cleaning Location(s) <br /> 6. 13 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> , No. Units Served <br /> Plant Capacity <br /> 7. d LAUNDRY For July 1,-June 30, 19 <br /> SIZE' ❑ Less Than 1,000 Sq. <br /> Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. <br /> + <br /> Ilcation and that the work will be done In accordance with San Joaquin County <br /> I hereby certify that I have prepared thls app <br /> ordinances,state laws, les and regulations of the n Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X �tk <br /> 1, FOR DEPARTMENT USE ONLY <br /> } > ❑ �S Reiyec By January 37 ❑ July t&Receivedeo By July 31 <br /> 1 Fee Is Due:.❑ ANNUALLY C] PER UNIT ❑ PER SITE ❑ EACH January ceREMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE ,DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> .OTHERMN <br /> Recelved by <br /> Dat Receipt No PermiLrvo. Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIROMMiNTAL HEALTH PERMIT/SERVICES .16019.HAZEL V!;P.O.Box 20tH 9TOCKTON.CA 6520 <br />