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APPLICATION , <br /> Non-Transferable,Revocable,and Suspendable' r ' <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE l <br /> LIQUID WkSTE � <br /> I Application is,,b ereby made I carryon b siness in the juns Ictional area of the San Joaquin Local Health Distnc <br /> 3usiness Name DBA) 2_.._� _._-.Address m '+` � � — <br /> c Owner elvl <br /> Address <br /> t <br /> ' Irm Partners,Addresses and Telephone Numbe <br /> 3usiness Telephone No. sv e Jr Emergency Telephone No. <br /> , "ontractor Licence No. 2— <br /> Applicants Name(Print) ' Title. Date to�� <br /> RTease check Applicable Category (1-7) and Fill in the Requir IMarmation <br /> 11PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> escription(Make/Yr-, Color) <br /> ;erial No. CAL. License No. CAL. Licc.se Renewal No. <br /> -Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> PUMPER YARD <br /> �' CI or July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> ro_of Chemical Toilets Stored. <br /> 1. ❑ PERCOLATION TEST <br /> R.S_or R.C.E. Name R-S.or R_C.E. No. <br /> est L cation Test Date/Time <br /> L <br /> est <br /> PERMIT <br /> 37 <br /> Job Address/Location <br /> O `Y 9 � �'�- -14[r Address <br /> ySEPTIC TANK ❑ CESSPOOL ❑ EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR <br /> OTHER 5A,140 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> Vo.of Units Equipment Storage/Cleaning Location(s) <br /> -6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location Y <br /> implant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> P-IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> -1 DRY CLEANING, Chemicals Used/Amount/Mo- <br /> F. <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 r and regula' ns of the San Joaquin Local Health District. <br /> PAPPLICANT'S SIGNATURE <br /> F_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is,Due: ❑ ANNUALLY ❑ PERUNIT. fXPER SITE ❑ EACH ❑ January.) &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE - $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTEE AMOUNT <br /> FEE t� <br /> LESS <br /> PRORATION <br /> PLUS <br /> -- PENALTY <br /> OTHER <br /> Fi I OTHER <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> r APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ' 16011 E.HAZELTON AVE.,PA.Box 2DO9 STpCKTO CA 5201 <br />