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- pplications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> jApplication i hereby m e to arty buglness in the jurisdictional area of the San Joaquin L al Healt istrict <br /> 1 y Business Name (DBAddres R <br /> _ Address d q <br /> aOwner <br /> 4 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No 11, ill Title 4C� �--- Date <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> dune 30, i9 Disposal Sites <br /> For July 1, <br /> Description(MakiColor) CAL. Lill Renewal No. <br /> Serial No. CAL. Licensll <br /> Capacity <br /> Gal ,Weights&Me ure`.No. 41 <br /> Equipment Parking'Address <br /> 2. ❑ PUMPER YARD <br /> For July 1}- dune 30, 1.9-` <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION TEST +1+• lam R.S. or R.C.E.No. S� <br /> f I.4. } „ <br /> R.S. or R.G.E. Name <br /> '*t Test Date/Time <br /> Test_Location .� <br /> 4. ❑ SANITATION PERM <br /> IT — �> <br /> ' 1 <br /> Job AddresstL cation <br /> Address <br /> O_net .` ` ❑ PACKAGE PLANT <br /> V❑ACESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> SEPTIC TANK r ❑ REPAIR <br /> PERMANENT ❑ TEMPORARY' NEW ° <br /> r ❑CHEMICAL TOILETS" For'Jul 1, -'June 30, 19� y t ' <br /> Type Construction Disposal Site I <br /> �. No. of Units <br /> Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 !r <br /> _W her_e,Cel;tified <br /> ( Operator Name R <br /> Plant Location <br /> No. Units Served �- <br /> Plant Capacity v <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> I ► 1 VA SOON <br /> I hereby certify that 1 have prepared this application and that,.th work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, a and re ns the Saes-doa n- oc -Health District.- <br /> I APPLICANT'S SIGNATURE X a <br /> k � %A A WKS •-' % FOR DEPARTMENT USE ONLY <br /> �a +p� I1 - _❑ACH �❑ January 1 &Received B :January 31, r ❑ July t &Received By July 31 <br /> Fee Is-Due. ❑ ANNUALLY �❑ PER UNIT 4 tl PER S REMIT 5 <br /> .{ $ CHECKED <br /> �,�.�.� BILLING REMITTANCE AMOUNT DUE <br /> BASE E_XPLANATi_O�! 3 - ATE DATE REMITTED AMOUNT <br /> u. <br /> CC� <br /> i FEE J - I <br /> r <br /> LESS or 1 <br /> PRORATION <br /> PLUS „f <br /> PENALTYl ""'^ <br /> OTHER tk <br /> t �tiA* S <br /> OTHER 7 <br /> p l ( Iss once Date Mailed <Jeliver �9?2101 r. Date Receipt N. Permit o. <br /> Received by 1601 E.14AZELTON AVE.,P.O.Boz 2009 STOCK ON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />