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�. ,4Applications Will Be Processed When Submitted Properly Completed. Besure io sign Inemppuz:auvrr. <br /> x APPLICATION 00 <br /> endable)(For Non-Transferable, Revocable,and Susp <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> c LIQUID WASTE <br /> Application is hereby made to carry on business the jurisdictional area of the San Joaquin cal Health District p� <br /> r Business Name (DBA) Address <br /> Address <br /> yg <br /> z Owner <br /> a <br /> J Firm Partners, AddresseAaTelep <br /> hone Numbers <br /> a. Business Telephone NoEmergency Telephone NoContractor Licence No..Applicants Name (PrintTitle Date e <br /> _51-7 and Fill in the Required Information <br /> Please check Applicable Category,( ) <br /> 1. ❑ PUMPER VEHICLE'PERMIT REGISTRATION (FOR EACH VEHICLE) { " <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. y' <br /> Serial No. CAL. License No. <br /> Capacity GaL, Weights & Measures No. _ <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD ` <br /> For July 1, June 30, 19No. of Vehicles'Stored <br /> I No. of Chemical Toilets Stored �- <br /> 3. El PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.-or R.C.E.No. <br /> _ - - a <br /> I Test Location -^Test Date/Time <br /> -� F Y <br /> 4. ❑ SANITATION PERMIT •. "� `� - <br /> Job Addres /Locatio , �" <br /> i OwneriW " . Address - i <br /> ❑ SEPTIC TANK ElCESSPOOL LEACHING FIELD 13 SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> t` 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 T <br /> Type Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Location(s) w F <br /> i 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> 4 Operator Name <br /> Pint Location <br /> t Na. Units Served <br /> ' <br /> PlantCapacity <br /> 7. ❑ LAUNDRY_ For July`1,"June 30, 19 ' F <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> s - a ,. <br /> I he by certify that I prepared Is applicatiori and t at the work 'II be done.in accordance with San Joaquin County <br /> j �� ordinances, st law , and ules and regul o of(h San oaq t District- <br /> APPLICANT'S SIGNATURE A <br /> S FOR DEPARTMENT USE ONLY <br /> Fee IS DUE: ❑ ANNUAtLY [3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received BY January-31 . ❑"July 1,.&Receiv REMITd By 31. <br /> ' BASE EXPLANATION BILLING R MITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t FEE <br /> LESS o ?►. <br /> PRORATION <br /> PLUS o - -Z _ <br /> PENALTY <br /> OTHER h. " <br /> t OTHER <br /> Received by <br /> Oat Receipt No. Permit o. _ Issuance_Date Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOGKTON,GA 95201 <br />