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roperly <br /> Applications Will Be Processed When SubAPPL`CATIONPIeteBe u <br /> /m••/ it <br /> y I (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is hereby made to car on businessA2ddress <br /> risdictional area of the San Joaquin Local Health District <br /> its Address <br /> wBusiness Name (Dn) <br /> i Ownerte <br /> a <br /> 2 Firm Partners, Addresses and Telephone Numbers ; <br /> I Emergency Telephone No. <br /> I a Business Telephone No. <br /> Contractor Licence No. <br /> g �' �-EF- — Date 37 ' � <br /> Title <br /> l 4 Applicants Name (Print) } <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, F June 30, 19 .q Disposal Sites <br /> I Description(Make/Yr., Color) II. <br /> GAL. License Renewal No. <br /> ��Serial No' t iE CAL. License No. <br /> ' Gal.,Weights &Measures No. <br /> I Cap city � iM <br /> Equipment Parking Address w - <br /> 2. ❑ PUMPER YARD �` <br /> For July 1, June 30, i9 i d <br /> No. of Vehicles Stored <br /> t No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I� <br /> R.S:or R.C.E.No. <br /> R.S. or R.C.E. Name IM !Test Date/lime ' <br /> Test Location <br /> 4. SANITATION PERMIT04 <br /> x <br /> 1 Jab Address�Lcon Address <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT N <br /> 13 PERMANENT E] TEMPO`RARY 11NEW ❑ REPAIR - --�I❑ OTHER <br /> i 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 r <br /> Disposal Site P <br /> Type Construction 1 <br /> Equipment Storage/Cleaning Location(s) j <br /> ?" No. of Units P <br /> 6. ❑ PACKAGE TREATMENT'iPLANT For July 1,-June 30, i9 Where Certified <br /> Operator Name Ip <br /> I Plant Location I� No. Units Served <br /> Plant CapacityY <br /> IL 7. 11LAUNDRY For July 1, -'fJune 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sg. Ft., 13More Than 1,000 Sq.'Ft. <br /> ❑ DRY CLEANING, Chemicals'' sed/Amount/Mo. <br /> I� k will be done in accordance with San Joaquin County <br /> l I hereby certify that 1 have prepared this application and that the war <br /> ordinances, state laws, and rule and regulations f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> •• <br /> pper� <br /> Fee is Due: ❑ ANNUALLYi <br /> ❑ PER UNIT ❑ PER SITE ❑ EAGH ❑ January 1 &Recai�ed By January 31 ❑ July 1 &Received REMIT <br /> uty 31 <br /> ih BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> i I <br /> FEE ' [ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I� <br /> OTHER I� <br /> su c Date Mailed Deli red <br /> "Date Receipt, Permit o. <br /> Received by ELTON VE., O.Box 2D09 ST KTON, 95201 <br /> ', APPLICANT—RETURN AL i COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES �j�R� — <br />