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-f Applications Will Be Processed When SubAmPltPL`roperty CATIONPIeted tiesure 1u -la .��r�4 f <br /> R �!i <br /> y (For Non-Transferable,Revocabie;and Suspendable) SEPTAGE. <br /> ° ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ca � n is hereby made t P car on business in the jurisdictional area oft _San aquin Local Huth Di�C� , , , <br /> Address 1�� <br /> hBusiness Name (DBA) Address Y - <br /> z Owner <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business.Telephone Nod. <br /> Contractor Licence No. ,_ C� - Title Date -� <br /> Applicants Name (Print) <br /> Please check Applicable Category-(1-7)and 1I the Required Information ; :.,,, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,-19 = Disposal Sites--- <br /> Description(Make/Yr., Color) `,CAL:License Renewal.-No. <br /> GAL:License No.- <br /> Serial No. <br /> Capacity -( Gal.,Weights &Measures No. , <br /> �„a ,� ... ..., . <br /> Equipment Parking Address" ' . <br /> 2. ❑ PUMPER YARD r <br /> For July i,' June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored, <br /> 3. ❑tPERCOLATION TEST , R.S.or R.C.E. No. <br /> R.S.or R.C.E. Name <br /> J-.4 1 Test Date/Time <br /> Test,Locaa Ion , <br /> 4. 1 SANITATION PERMIT <br /> Job Address/Locations <br /> Address <br /> Owner ❑ PACKAGE PLANT O <br /> ❑ SEPTIC TANK ❑ CESSPOOLS L f LEACHING FIELD L'� SEEPAGE PIT ❑ OTHER <br /> TEMPORARY �. 11NEW �R7=PAIR 1' <br /> L�'1SERMANEN7 T <br /> 5. ❑.CHEMICAL TOILETS For July 1; June 30, 19 <br /> _,Disposal Site <br /> Type Construction " t <br /> No. of Units �F• ,��"Equipment Storage/Cleaning Location(s) CA <br /> 6. 1:1PACKAGE TR£ATMENT.`PLANT For July 1, -June 30, 1`9 µ Where Ceitied r <br /> Operator Name s ' <br /> Plant LocationI _ Y <br /> c `+', �" � No. Units Served • "'•'} <br /> Plant Capacity <br /> r I <br /> 7. 11 LAUNDRY For July,1June 0, 19, - I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.; ❑ More Than 1,()00 Sq" Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> _.N '� ■• - � ,.,aura, — P .. <br /> j I hereby certify that if x `e.prepared,this applicati d th wk will be done in accordance with San Joaquin County <br /> Sa Jo in' oval Health.District. <br /> ordinances, state law a d les and r lation �=4 <br /> APPLICANT'S SIGNATURE ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: C3 ANNUALLY PER UNIT El-PER SITE ❑ EACH ❑ January 1 &Received By January 31= ❑ July 1 &ReceivedJuly 31 <br /> REMIT <br /> F <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE REMITTED AMOUNT <br /> r DATE � <br /> V ` <br /> FEE I I <br /> LESS v 1 <br /> PRORATION <br /> PLUS ✓ ' <br /> PENALTY <br /> s <br /> _ OTHER <br /> OTHER '� M <br /> Permit No. Issuance Date Mailed _t Delivered <br /> Received by Date Receipt No., CA 95201 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box! <br /> APPLICANT—RETURN ALL COPIES TD: D09' 5TQCKTON, <br />