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' Applications Will Be Processed When SubAmPtPeLICATION <br /> "F For Non-Transferable,Revocable, and 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH <br /> PERMIT <br /> LIQUID <br /> Application is eby made to arty on b mess in the jurisdi tonal area of the Joa Local Health trict <br /> Address <br /> I <br /> F Business Name (D ) Address <br /> aOwner <br /> Firm Partners, Addresses and Telep 'umbers Emergency Telephone No. <br /> IL Business Telephone No. Q —� <br /> ,� Date <br />` a Contractor Licence No. 7Qh Title <br /> Applicants Name (Print) <br /> Please check Applicable Category.(1-T1 and FIII in the Required Inior lion. <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 1. June 30, 19 '�M� Disposal Sites <br /> For July 1, ,II <br /> No. <br /> Description(Make/Yr., Color) CAL. Lic.:�se Renewal <br /> yl7 CAL. License No, <br /> Serial No. IM hts &Measures No.Gal.,Weig <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I 1,— <br /> June 30, 19 <br /> For JulyIM <br /> No. of Vehicles Stored <br /> t. No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST N R.S. or R.C.E.NO. <br /> " R.S. or R.C.E.Name If, Test Date/Time c <br /> Test Dation e <br /> [ q, IJ SANITATION PERMIT r �iCi <br /> y Job Address/L c ,tion I'. Address <br /> Owner T 13 PACKAGE PLANT <br /> ❑ SEPTIC TANK 11CESSPOOL LEACHING FIELD ❑ OTHER <br /> ❑ PERMANENT <br /> ❑ TEMPORARY El NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction ,il <br /> Na. of Units Il Equipment Storage/Cleaning Location(s) <br /> rt <br /> g. 11 PACKAGE TREATMEN i PLANT For July 1, - June 30, 19 Where Certified <br /> Operator Name <br /> r Plant Location I� <br /> No. Units Served <br /> Plant Capacity <br /> 7, C3 LAUNDRY For July 1,. June 30, 19 <br /> f q. Ft., ❑ More Than 1,000 Sq. Ft, <br /> SIZE: 13 Less Than 1,000 5 <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> } t I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> hereby certify tha <br /> F. , and ru sand regulations of the San Jyiui <br /> �a n Local Health District. <br /> ordinances, state lbws <br /> APPLICANT'S SIGNATURE X <br /> I � <br /> FOR DEPARTMENT USE ONLY <br /> PER SITE [1-EACH January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> Fee Is DUe: ❑ ANNUALLY [3 PER UNIT REMITTANCE $ AMOUNT DUE CHECKED <br /> 4. BILLING REMITTED AMOUNT <br /> I <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS II <br /> PENALTY JJJIII <br /> OTHER <br /> OTHER IN _ O ,�,� -d-7 <br /> % S 7 <br /> ! 9�� Issuance Date Mailed Delivered <br /> Receipt No Permit No. <br /> Received by .I�. Date 1601 E.HAZELTON AVE.,P.O.90=2009 STOCKY ,CA 45 1 <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />