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Applications Will Be Processed When Submitted Properly Complete d. Besure <br /> APPLICATION 1�� <br /> (For Non-Transferable, Revocable,and Suspendable) 3r.p0 SEpTAGE I) <br /> ENVIRONMENTAL HEALTH PERMIT F <br /> LIQUID WASTE <br /> 11 ��A0�r <br /> Applica is here ode to carry an business in the jurisdictional area of the San Joaquin Local Health District <br /> a Address <br /> rBusiness Name (DBA) Address <br /> z Owner <br /> 4 <br /> J Firm Partners, Addresses and Tel hone Numbers� Emergency Telephone No. k <br /> aBusiness Telephone No. <br /> Contractor Licence No. 0 <br /> l Date <br /> Title <br /> Applicants Neme (Print) <br /> Please,check�Applica�ble,�Cattegory (1-7) and Fill in the Required Information �+ <br /> 1, [3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> .*&dune."19 Disposal Sites <br /> For July 1, <br /> Description(Make/Yr.,Color) CAL, License No, CAL. License Renewal No. <br /> Serial No. I <br /> Capacity Gal.,Weights &Measures No. a <br /> Equipment Parking Address A <br /> 2. ❑ PUMPER YARD <br /> For July 1, <br /> j'iIn e 30, 19 r' I <br /> - E d <br /> No. of Vehicles Stored "15 r <br /> No. of Chemical Toilets Store41 <br /> d „ 'i <br /> f 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. Q <br /> R,Sx. or R.G.E. Name Test Date/Time <br /> 7est'wocation — f++r / <br /> 4. (SANITATION PERMIT "3� <br /> Job Address/ tionjit�� F I .,, -Address ¢` <br /> ;.rt, r u�; ram 4 <br /> Owner s- LEgCHING FIELD Jfl SEEPAGE PIT ❑ PACKAGE PLANT <br /> "1 ❑�CESSPOOI �r <br /> ❑ SEP7lG TANK ❑ OTHER <br /> � , °{ ❑ NEWRi PAIR <br /> PERM I ENT ❑ TEMPOA,. y <br /> Z <br /> . �. <br /> V 5, ❑ CHEMICAL TOILETS Foruuly 1, -June 30, 11.9 <br /> 16sposal Site <br /> Type Construction <br /> No. of Units Equijrinenti*St6rage/Cleaning-Locetion(s) " <br /> )f. <br /> 1f6F 11 PACKAGE TREATMENT PLANT For July �, #une 30, 19 Where Certified-4 <br /> Operator Name . <br /> Plant Locations — <br /> No. Units Served <br /> PI 't'Capacity <br /> 7, ❑ LAUNDRY For July 1,-Ahe 3019 <br /> SIZE: ❑ Less Than 1,000 Sq.*F.t, [3 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Us d/Amount/Mo. <br /> I <br /> 6 <br /> 1 hereby certify loaf 1'have prepared.t is,atpplic of the SathJoaquin LocallHeall lth District. <br /> done in accordance with San Joaquin County <br /> ordinances, stateaaws, an es and g ^ i <br /> Ilikl <br /> APPLICANT'S SIGNAT, <br /> N <br /> win=4 FOR DEPARTMENTUSE ONLY <br /> "PER'SI7E� 'O-EAC1i �❑ Jarwary 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> Fee Is Due: JAINUALLY ❑ PER UNIT �,3�B`LLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION i .�.}��k p'AT.E_ DATE REMITTED AMOUNT <br /> i FEE <br /> } <br /> LESS - <br /> v PRORAT ON <br /> PLUS <br /> f .. <br /> PENALTY } <br /> OTHER i <br /> Issuance Date Mailed Delivered <br /> +}i w,. a ReceiQt No. Permit No.{ OA 9524 <br /> { �.3�7I-'Aeceived-by' Date - 1601 E.HAZELTON AYE.,P.O.Box 2049 STO_CKTON, <br /> APPLfCANT�RETURN ALL COPIES TO: ENYIRONINENTAI_}{EALTH PERMITlSERYIGES y � +,� �� '� <br />