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_ - _ �.ronlpl`vv <br /> - - Appllcations Will Be. rocessed Wtien su�AmPPLICATION F <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE -W-- <br /> .50 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> to carry on business is in the jurisdictionaAdd of the San Joaquin Local Health District <br /> Application is hereby made r <br /> 11 <br /> Basin ame (DBA) { �7� � <br /> z Owner r A �•` <br /> K Telephone No. <br /> S2 Firm Partners, Addresses and Telephone Numbers Emergency P <br /> -Zta.7 <br /> aBusiness Telephone No. i r Date <br /> t Contractor Licence Na. l SO Title W <br /> AppName Name (Print) <br /> (1-7)and Fill in the Required Information <br /> Please check Applicable Category <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOREACH <br /> V HICLE) <br /> For July 1, June 30, 19 Disposal <br /> GAL. License Renewal No. .�, <br /> Description(Make/Yr.,Color) CAL. License No. <br /> t Serial No. <br /> Gal.,Weights &Measures No. <br /> .I Capacity <br /> Equipment Parking Address J <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored . <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E.Name Test Date/Time <br /> Test Location <br /> 1 4.>eSANITATION PERMIT /V+t.. G Jr <br /> Job Add ss/Location S� o n Address ❑ PACKAGE PLANT <br /> R <br /> Owner LEACHtNG FIELD ❑ SEEPAGE PIT <br /> fg�SEPTIC TANK ❑ CESSPOOL q5� ❑ REPAIR ❑ OTHER <br /> IETPERMANENT ❑ TEMPORARY rKEW i <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> I. Plant Capacity <br /> 1 7, ❑ LAUNDRY For July 1, -June 30,09 <br /> More Than 1,000 Sq, Ft. <br /> I SIZE. ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> tnand that the work will be done in accordance with San Joaquin County <br /> this application <br /> I hereby certify that I have prepared <br /> f the San Joaquin <br /> ordinances, state laws, a rules and reg ations oY �cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> `f FOR DEPARTMENT USE ONLY <br /> 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER 517E ❑ EACH ❑REMITTANCE <br /> $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> ¢l uJ <br /> FEE lr' � <br /> t LESS <br /> CI <br /> l PERORATION \ <br /> PLUS \\ <br /> PENALTY ,. . <br /> OTHER <br /> r <br /> I OTHER <br /> I /1 <br /> Issuance Date Mailed Deliv ed <br /> Receipt No, Permit No. 5201 <br /> Received by � Date 7 � 1601 E.IiAZELTON AVE.,P.O..Bo>t 2009 57.9 Tp <br /> C <br /> : ENVIRONMENTAL HEALTH PER M171SER <br /> APPLICANT—RETURN ALL COPIES TOYICES <br />