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t- - .rte �._.s -•-�-" rly Completed, tie aury , Ls -,y..... _ <br />Applications Will Be Processed When Submitted Prope <br />APPLICATION' >- <br />(For Non Transferable, Revocable, and Suspendable)'�-• SEPTAGE <br />ENVIRONMENTAL HEALTH, PERMIT <br />LIQUID WASTE <br />ere m to carryon usiness i the jurisdi tional area of th an aqui Loc I Health D' trio <br />Application Address v <br />a Business Name (DBA) Address <br />Owner,;, <br />J Firm Partners, Addresses and Telephone umb rs �Emergency Telephone No: f <br />aBusiness Telephone No. S <br />trontractor Licence No. % — Date <br />� I i <br />Applicants Name (Print) p 1 <br />Please check Applicable Category (1-7) and Fill In the Required Information <br />1, <br />[3 PUMPER VEHICLE PERMIT REGISTRATION (DOPo alCS t s HICLE) <br />For July I. June 30. 19 — � N <br />Description (MakeNr., Color) CAL, License Renewal No.- <br />CAL. License No. <br />Serial No. <br />Capacity Gal., Weights &Measures No. -- — — <br />Equipment Parking Address 1 <br />2. ❑ PUMPER YARD —yam <br />t For July 1, - June 30, 19 - — <br />II No. of VehlCles Stored <br />No. of Chemical Toilets Stored — <br />I 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. — <br />F R.S. or R.C.E. Name Test Date/Time <br />Test ocation <br />4. SANITATION PERMIT �! <br />Job Addr Location �FIEL <br />ress <br />�Owner LEACHINSEEPAGE PIT ❑ PACKA E PLANT' <br />I ¢* SEPTIC TANK ❑ CESSPOOL ❑ REPAIR ❑ OTHER <br />iC <br />PERMANENT ❑ TEMPORARY NEW ' .� <br />5. ❑CHEMICAL TO For July 1, - June 30. 19 <br />Disposal Site —— <br />�. Type Construction ��-- <br />Equipment Storage/ Cleaning Location(s) <br />t No. of Units — 1, - June 30, 19 <br />"g. ❑ PACKAGE TREATMENT PLANT For July J _ Where Certified <br />I Operator Name-- _ <br />1b Plant Location No: Units Served <br />I' Plant Capacity —19 <br />} ❑ LAUNDRY For July 1, - June 30, — <br />7.- ❑ More Than 1,000 Sq- Ft. - <br />SIZE ❑ Less Than 1,000 Sq. Ft., <br />❑ DRY CLEANING, Chemicals Used/AmounVMO. <br />L <br />1 hereby certify that I have prepared this application and that the Localill be <br />one D sti naccordance with San Joaquin County <br />LIM <br />t. <br />ordinances, state laws, an rules and r Ulati the <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />t b eiv January 31 ❑ July 1 & Rece.ved 8y July 3t <br />PER SITE ❑ EACH ❑ January REMIT <br />$ CHECKED <br />Fee is Due: ❑ ANNUALLY ❑ PER UNIT BILLING REMITTANCE A OUNT DUE <br />i BASE PLANATION DATE PATE ITT D <br />AMOUNT <br />c � ' <br />FEE S <br />LESS <br />-Q� PRORATION ---� <br />PLUS <br />PENALTY <br />OTHER , <br />OTHER <br />1 ""^�'•nc p/t Mailed aged Deliver <br />Receipt No. Permit rao. !; <br />- Received by Date � 180t E. NAXELTON AVL-, A.O. Boa 4009 S70CK ON, CA 9 t <br />-APPLICANT—RETURN ALL COPIES TO: ENvIRONMENTAL HEALTH PERMIT15ERVICES � / <br />