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M Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppticauon. J <br /> APPLICATION <br /> =^ (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ' !s hereby �Vetoapon bus! �i elsdtional area of the, aJoaquirlLocal eatri 4 <br /> Address <br /> m Business Na e (DBA) S G. <br /> I Owner Address <br /> a <br /> a Firm Partners, Addresses and T lephhone Numbers <br /> Emergency Telephone No. <br /> a Business Telephone No. <br /> / r <br /> Contractor,Licence No. Date g <br /> Title P <br /> Applicants-Name(Pr'int)• <br /> "'., c `' ` 1-7 and Fill in the Required Information <br /> Please+✓heck Applicable Category ( ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, f June 3019 Disposal Sites ! <br /> Description(Make/Yr., Color) CAL. License Renewal No. 1 <br /> Serial No. CAL. License No. i <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> s <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 A <br /> R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name <br /> ?Test Location Test Date/Time r <br /> 4. ❑ SANITATION PERMIT "`- l — /O�` 71—;4,,- '��541A , <br /> IJob Address/Location S� 7e 5'rochilely", <br /> IOwner C I Aut 11110a—'5 Address ❑ PACKAGE PLANT <br />( SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> PERMANENT ❑ TEMPORARY NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I Equipment Storage/Cleaning Location(s) <br /> No, of Units <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name ° <br /> Plant Location - <br /> No. Units Served <br /> Plant Capacity j <br /> i7. ❑ LAUNDRY For July 1, -June 30, 19 r <br /> 1SIZE: ❑ Less Than '1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and a and regulati ns Local Health District.of the an Joaquin ( <br /> t <br /> tAPPLICANT'S SIGNATUREX g` <br /> f i FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Due: ❑ ANNUALLY PER UNIT �PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedJuly 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION DATE DATE REMITTED !r1 {AMOUNT <br /> f � FEE <br /> , <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER , <br /> O <br /> .OTHER"t { -1<' A <br /> Received by Date <br /> Receipt No. Permit No. Issuance Dates Mailed * Delive d <br /> _ t601 E:HAZELTON AVE.',P.O.Box 2009 STOC TON,C 95201' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> +� ►� ;' <br />