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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicata .1. r APPLICATION endable) (For Non-Transierable,Revocable,and Susp SEPTAGE � ENVMORI&NTAL HEALTH PERMIT LIQUID WASTE Applicatio is hereby�adeto.�ar bu n in the jurisdictional area of the S + loa Local Health trict Business e (DBAi - . �,_ - 7��/`��A�ddresr,_ ` �T C• r r I aOwner_ - 9 (OV- Firm Partners, Addresses and Telephone,�Number s Business Telephone No. 13 ✓`' — Emergency Telephone No. a Contractor Licence No. - aGr�NyKr _ Date _ a Applicants Name (Print] _ Title Please check Applicable Category (1-7)and Fill in the Required Information V 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) For July 1, ,June 30, 19 _--_ Disposal Sites - Description(Make/Yr.,Color) -- CAL. License _CAL.License Renewal No. No. �J J Serial No. -= _ - ` Capacity _ Gal_Weights & Measures No. —r V Equipment Parking Address_ - 2. ❑ PUMPER YARD For July 1,_ June 30. 19 No. of Vehicles Stored No. of Chemical Toilets Stored --- -- - - 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. R.S. or R.C.E, Name - Test Location Test Date/Time - 4. WJSANiTATION PERMIT Job Address/ ocation � - Owner �- Address - ET'SEPTIC TANK [3 CESSPOOL LEACHING FIELD ❑ SEEPAGE P17 C1 PACKAGE PLANT Q PERMANENT ❑ TEMPORARY 9 NEW ❑ REPAIR ❑ OTHER ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - ype Construction Disposal Site No of Units — - -- Equipment Storage/Cleaning Location($) - 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19_._ Where Certified - _- Operator Name _ Plant Location -- No. Units Served — i Plant Capacity 7. ❑ LAUNDRY For July 1, - June 30, 19— SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ❑ DRY CLEANING,Chemicals Used/Amount/Mo. -- - - I hereby certify thatI have p ared this a plication and that the work will be done in accordance with San Joaquin County ordinances,State laws, an es end regu ns f the San Joaquin Local Health District APPLICANT'S SIGNATURE X - I - FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER.SITE _ ❑ EACH ❑ January 1 &Received By January 31 ❑ Jlily 1 &Hecel�RBy EMIT`ly 3. ` Ir BILLING REMITTANCE a AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT _ FEE LESS -- PRORATION - ttI PLUS - PENALTY I - OTHER - OTHER - _- - --- Malled DeYI red J Date ReCei pt N. .... Permit No. Issuance mate Received by 1so1 E.HAZELTON AVE.,P.O.Bo 9 ST KION.CA 95201 ..L — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SEHYICES �r�- /7�