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Applications Will Be Processed When Submitted Properly Complete a ure <br /> - APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is eby made to carry o ,business in the jurisdictional area of th r aan J,�quin L ca�ealth District / <br /> r <br /> P3 P_ <br /> Address <br /> v, Business Name (DBA) <br /> I.- <br /> Owner <br /> Address <br /> J Firm Partners, Addresses and Tole ho NumbersEmergency Telephone No. <br /> a. Business Telephone No: G f <br /> Contractor Licence No. T pate <br /> • j Title �_. <br /> Applicants Name (Print) ' <br /> Please check Applicable Category(1-7)+and Fill in the Required Intormation. ? „ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> �� - ., + <br /> For July 1, June 30, 19- - Disposal Sites 4 x <br /> Description(Make/Yr., Color) �~ <br /> CAL. License No. "" ;. CAL.'License Renewal`No. vy <br /> Serial No. ' 4 <br /> Gal , eights &Measures No. <br /> . W <br /> Capacity <br /> Equipment Parking Address �.w <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored V_ o <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ RS.or R,.C.E.'N61, <br /> R.S. or R.C.E. Name 1 ► <br /> TTest Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> 99 MW-Ay <br /> Job Address/L cati <br /> Alr� f�i Address AD <br /> Owner , <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 0 SEEPAGE PIT PACKAGE PLANT _ <br /> PE OTHER V �A,pl,j <br /> � <br /> PERMANENT 13 TEMPORARY ;5 NEW fREPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Disposal Site <br /> construction �� it <br /> No. of Units Equipment storage/Cleaning L'ocation(s) O, <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 � Where Cer�tiied°a_ F <br /> Operator Name <br /> Plant Location �.� <br /> Plant Capacity _No. Units Served i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. a <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. + s <br /> I hereby certify that I have prepared this application and that the work willbe done i6-accordance with San Joaquin County <br /> t <br /> # ! 1Q <br /> ordinances, state laws, and r es and re ula ons of t uin n Joa Local Health District° <br /> APPLICANT'S SIGNATURE X I f <br /> _ & '� <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due" ❑ ANNUALLY ❑ PER UNIT. Cl PER SITE ❑ EACH ❑.January 1 &Received By January 31 ❑ July t &ReceivedREMITuIy 31 <br /> CHECKED <br /> R'r4 �.yam+ 3 , 81LL'ING ..-REMITTANCE $ I AMOUNT DUE _ <br /> BASE EXPLANATION DATE ❑ATE REMITTED a AMOUNT <br /> FEE <br /> L <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> S.0 <br /> OTHER a '+ y <br /> OTHER } t <br /> Date 'Receipt No' Permit No. <br /> s ce Date Mailed Delivered <br /> Received by _ �80� ELTON AVE.,P.O.Box 2009 S70CKTON,CA 95201 , <br /> + APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH 0ERM SERVICES <br />