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- a Applications Will Be Processed When SuAPPL�CATION <br /> m (For Non-Transferable,Revocable,and Sus <br /> pendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE' �p tri <br /> Application is reby a to carry on sin in the jurisdictionalAaa of <br /> stheSan J a in Local He <br /> yBusiness Name (DBA Address <br /> aOwner <br /> EFirm Partners, A dres es and Telephone Numbers Emergency Telephone No. <br /> I d Business Telephone No. Date <br /> 4 < <br /> Contractor Licence No. I Title } <br /> Applicants Name (Print) Fill <br /> -Please check Applicable Category (1-7) and in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 Disposal Sites <br /> For July 1, p <br /> GAL. Lic:.^,se Renewal No. <br /> I <br /> Description(Make/Yr., Color) CAL. License No. <br /> Serial No. <br /> Gal.,'Weights &Measures No. <br /> Capacity I <br /> Equipment Parking Address <br /> 2, ❑ PUMPER YARD <br /> For July i, June 30, 19 <br /> No. of Vehicles Stored 1 <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 I - Test Date/Time <br /> l Test Location O <br /> j q_ 11 SANITATION PERMIT f�7 <br /> Job Address/Lo ation j 4l Address <br /> Owner ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSP OL REPAIR 11 OTHER <br /> 13 TEMPORARY ❑ NEW <br /> ❑ PERMANENT 1,-June 30, 19 <br /> 5, [1 CHEMICAL TOILETS For July Disposal Site <br /> Type Construction Equip ' <br /> ment SDispo ai Site <br /> ing Location(s) <br /> No. of Units <br /> g• 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1, -June 30,[9More Than 1,000 Sq, Ft. <br /> SIZE: 0 Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a d regulations he San Joaquin Local alth District. <br /> i APPLICANT'S ATURE X <br /> /1,o _ old <br /> FOR DEPARTMENT USE ONLY <br /> C1 January i &Received BY January 31 ❑ July 1 &Received By Sufy 31 <br /> REMIT <br /> [ Fee Is Due: C1 ANNUALLY <br /> PER UNIT ❑ PER SITE ❑ EACH REMITTANCE $ AMOUNT DUE CHECKED <br /> f BILLING REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE Lam" <br /> LESS j r <br /> PRORATION <br /> [ PLUS <br /> PENALTY � <br /> OTHER <br /> i OTHER <br /> I; Permit No, Issuanc Date <br /> Date Receipt No. <br /> Received by t66l E.HAZEL70N AVE.,P.O.Box 2049 , 57OCK7ON,CA 9520 <br /> APPLICANT -RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMI715EflYICES <br />