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3` MvpiicauonsWill Be Processed When Submit-ted Properly Completed- Be Sure To Sign The Application. <br /> M APLICATION `"- <br /> (For Nan-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' SEPTAGE <br /> APAlicat• n is-hereby �IQUIQ WASTE <br /> y Business Name �pBq) �adetoc r on�busfis in h jurisdictional area of th <br /> c Owner_ n oaquin"Local Health_District. d <br /> Lam' Address - <br /> jFirm Partners, Addresses an Telephone Numbers Address <br /> CL Business Telephone No., <br /> Contractor Licence No. Emergency Telephone No: . <br /> .Applicants Name (Print] <br /> Please check Applicable Category - Title <br /> +f � S.iY(R, and.Fill in the Required Information ate" <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Juiy 1, f <br /> ascription(Make/Yr., Color) Disposal Sites <br /> Serial No. <br /> 'Capacity "-----•- .--� CAL. License•Nb. <br /> " '"Gal.~Weights-& MeasurWNO; '� f "CAU. License Renewal No, <br /> EquipmentParking Address - .�t. .._.�.;L _ <br /> 2. ❑ PUMPER YARD <br /> For-July 1,_ June 30, 19 "til <br /> No. Of Vehicles Stored , <br /> No- of Chemical Toilets Stored <br /> 3- ❑ PERCOLATION TEST _ <br /> 1 } <br /> R.S. or R.C.E. Name " !'.. <br /> Test Location + R.S. or R.C,E. No. <br /> 3 l <br /> 4• ❑ SANITATION PERM T Test Date/Time <br /> Job Addre Location 1 <br /> s <br /> co' -S <br /> SEPTICfr-x TANK ❑ CESSPOOL Addess <br /> LEACHING FIELD t SEEPAGE PIT ❑ PACKAGE PLANT. <br /> PERMANENT ❑ TEMPORARY <br /> 5• ❑.CHEMICAL TOILETS~ For July 1, _Ju e 30, 19 REPAIR ❑ <br /> OTHER <br /> Type Construction I t e <br /> No. of Units a Disposal•Site ^" <br /> =_ Equipment:Storage/Cleaning Locations) <br /> PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Y <br /> Plant Location Where Certified <br /> .Plant Capacity <br /> 7.-0LAUNDRY For July 1, -June 30, 19 No. Units.Served <br /> SIZE: ❑ Less Than 1,000 S Ft., ❑ % <br /> Sq. More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. 11 <br />�^ I hereby certify_t at l Have prepared this application and'that the work'lvili be done in accordance with San Joaquin County <br /> ordinances, state"law -,lar -Nd rul s andl <br /> an Joaquin Local'Healtfi District. <br /> i <br /> 4 <br /> APPLICANT'S SIG <br /> NATUR <br /> FOR DEPARTMENT USE ONLY { <br /> Fee Is Due: ❑ t <br /> ANNUALLY Cl PER UNIT' ❑ PER SITE O�EACH � � ¢ � <br /> ❑ January 1 &Received By January 31 - ❑ July 1 &Received 8y July3_a d <br /> r <br /> i' BASE EXPLANATION r BILLING' REMITTANCE $ REMIT 1 <br /> CHECKED <br /> DATE ± AMOUNT DUE . <br /> DATE t REMIT-TED <br /> FEE AMOUNTi <br /> I LESS <br /> e PRORATION <br /> F PLUS <br /> PENALTY >�`*•.�„l. f dS 1 ,�sj <br /> OTHER ' if <br /> a OTHER <br /> Re ved by Date Receipt No a <br /> " P jPermit No. 'zj Issuance Date Marled <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALPERMIT/SERVICES <br /> HEALTH _ <br /> 1601 E.HAZELTON AVE.,P.O.8nDelivered <br /> V0tS KTON,CA 95201 <br /> 11\\ <br />