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Applications will ao ---- APPLICATION <br /> • (For Non-Transferable,Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL WAHEALTHSTE PERMIT , <br /> ion is hereby ade to carryon business in the sdietionalgadree eosfsthe San Joaquin °CaQ Health District — <br /> gpplicat ��, ��.-�—.0 — <br /> Business Name (DBA) A� Address - — - <br /> Owner —�- <br /> Emergency Telephone N0. <br /> Firm Partne�Adresses, ani/'eilehone Numbers <br /> — — -� <br /> Business Telephone No. <br /> Contractor Licence No. Till <br /> Applicants Name (Print ---- <br /> ory (1-7) and Fill In the Required Information <br /> Please check Applicable Categ <br /> C1 PUMPER VEHICLE PERMIT REGISTRATION (FODisposal�CSites to VEHICLE) �{ <br /> For July 1,_ June 30, 19 —�` <br /> CAL.License Renewal No. <br /> Description(Make/Yr.,Color) CAL. License No. <br /> Serial No. —�—� <br /> Gal.,Weights & Measures No._. <br /> Capacity -- `------ <br /> Equipment Parking Address --- <br /> 2, ❑ PUMPER YARD —1—= <br /> For July ,_,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. J-- <br /> R.S. or R.C.E. Name --- - Test Date/Time_ <br /> TestLocation _ —� <br /> y_ 00 SANITATION PERMIT _ L� oil1�— <br /> Job Address/Location Address—�� <br /> ❑ LEACHING FIELD /M SEEPAGE PIT PACKAGE PLANT <br /> Owner — ❑ 0T1iER "- <br /> SEPTIC TANK D CESSPOOL C1 REPAIR Q TEMPORARY NEW <br /> ❑ PERMANENT 1 _June 30, 19 - <br /> 5 13CHEMICAL.TOtLETS For July Disposal Site <br /> Type Construction Construction <br /> Equipment Storage/Cleaning Locations) <br /> No. of Units _June 30, 19 <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1 Where Certified----------- -- <br /> Operator Name _ f <br /> I plant Location — No. Units Served <br /> Plant Capacity June 30, 19. <br /> 7, [1 LAUNDRY For July 1,- ❑ More Than 1,000 Sq. Ft. <br /> 1 SIZE: 1:33 Less Than 1.000 Sq. Ft., —1--� C <br /> k ❑ DRY CLEANING,Chemicals Used/AmounVMO. <br /> l <br /> )plication and that the <br /> work will be done in accordance with San Joaquin County <br /> 1 hereby certify that I have prepared this at <br /> ordinances, state la and rules and regulation f the San Joaquin Local Health District. ` <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE-ONLY <br /> - gt ❑ July 1 8 Received By July 31 <br /> PER UNIT ❑ PEA <br /> ❑ EACH ❑ January 1 &Received By January REMIT <br /> ❑ SITE CHECKED <br /> Fee is Due'.O,ANNUALLY REMITTANCE $ AMOUNT DUE AMOUNT <br /> Bit LING REMITTED <br /> r BASE EXPLANATION DATE DATE - <br /> - — <br /> FEE <br /> LESS _— <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER �- <br /> 3 isuace Date MMold lklrvfere -- <br /> C 6TOCKTOA 95201 <br /> Receiv <br /> Recelpt No .O.Boa 20o9 N,by <br /> ate 1601 E.NAZELTON AVE.,AVE.,' <br /> �— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE <br />