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.�-- —" <br /> f, Applications Will Be Processe�hen Submitted Properly Completed. Be <br /> APPLICATION <br /> (For Non-Transferable,Revocable,'and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> LIQUID WASTE <br /> licatio is hereby made to carry on business in the jurisdictional area of the San Joaquin cal Health Di`rict <br /> App Address <br /> NBusiness Name (DBA) Address -4-1 <br /> dOwner <br /> Firm Partners, Addresses and T ephone Numbers <br /> Emergency Telephone No. <br /> IL Business Telephone No. <br /> Contractor Licence No, Title Date <br /> I a Applicants Name (Print) <br /> r Please check Applicable Category (1-7)and Fill in the Required Information. <br /> 1. ,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> f For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) t CAL. Lic zznse Rerlewal No. <br /> Serial Na. CAL. License No. <br /> 'Gal.,Weights &Measures No. <br /> Capacity <br /> c <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD x <br /> June 30, 19 <br /> For July 11 ! <br /> No. of Vehicles Stored „ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ±4 R.S. or R.G.E. No. <br /> R.S. or R.C.E. Name ;Test Date/Time 4 <br /> Test Location e� 7� <br /> 4. ❑ SANITATION PERMIT 4ii <br /> Job Address/Location Address C <br /> Owner <br /> L(SEPTIC TANK C3CESSPOOL M:LEACI I1NG FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ REPAIR 11 OTHER <br /> 13 PERMANENT ❑ TEMPORARY R�NEW �s >.;� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19"Disposal Site <br /> + <br /> Type Construction - <br /> No. of Units Equipment Storage/Cleaning Location(s) Y <br /> g. 13PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> I Operator Name <br /> Plant Location <br /> Na. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, - June 30,19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that t one in accordance with San Joaquin County <br /> -ld <br /> h ordinances, state laws, and r)les and regulations of the S oaquin Local Health Di�s <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ EACH ❑ Janu 1 &Receive January 31 C] July 1 &Received By July 31 <br /> J. Fee is Due: El ANNUALLY ❑ PE ¢NIT �PER SITE REMIT <br /> p RILL, 11, REMITTANC $ AMO NT DUE CHECKED <br /> 1 BASE EXPLANATION DAT f DREMITTED AMOUNT <br /> V <br /> FEE a " <br /> k N <br /> LESS <br /> PRORATION <br /> 5 <br /> PLUS <br /> PENALTY r <br /> F OTHER y <br /> I " <br /> -21 <br /> CTHER _�- <br /> }1� Permit No. Issuance Date Mailed D Owe d <br /> Received by Date Receipt No. <br /> : ENVIRONMENTAL HEALTH PERMIT15EflYICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 20 <br /> APPLICANT-�RETi1RN'ALL COPIES TOU9 STOC TON,CA 9 201 <br />