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Applications Will Be PrI ed When Submitted Property Completed.Be Sino Sign The Application. <br /> APPLICATION <br /> k. (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby made to car on bu iness in the juri ictionai area of the 5 Jo uin Leal Health D <br /> Address - ti .., i <br /> y Business Name (DBA) 7 ' <br /> aOwner Address <br /> Firm Partners:Addresses and Telephone Nucm0bers Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. Date 3 <br />� L Applicants Name (Print) - �— Title <br /> Please check Applicable Category(1-7)and Flit in the Requi d Information <br /> 17"'EI PER VEHICLE PERRMIT REGISTRATkON (FOR EACH VEHICLE) <br /> M <br /> For:Julyal, - Ju 36,89 Disposal Sites <br /> f Description IMake/Yr.,ColorjV <br /> CAL. License Na. CAL.License Renewal No. <br /> Serial"110: .r'ti <br /> CapacIFity s Gal.,Weights&Measures No. <br /> Equipment Parking,Address' <br /> 2. PUMPERiAR6. <br /> For July 1, June 30,19 <br /> No.of Vehicles Stored <br /> Na.of Chemical Toilets Stored - <br /> 3, ❑ PERCOLATION TEST <br /> R.S.or R.C.E. No. <br /> ' R.S.or R.C.E. Name. <br /> TesXSL _ on k lest Date/Time _ <br /> 4, l!7 SANITATION PERMIT 0 <br /> Job Address/Location Ilk <br /> Owner Address_; s <br /> ❑ SEPTIC TANK ❑ I�ESSPOOL 1:1 LEACHING FIELD �r�SE "GE PIT ❑ PACKAGE PLANT Q` <br /> ❑ PERMANENT ❑ �ENIPORARY <br /> © NEW ►�'FtEt'AI0i ❑ OTHER <br /> 5. 11CHEMICAL TOILETS For July 1,-June 30, 19 A ' <br /> Type Construction ki Disposal Site <br /> No.of Units Equipment Storage/Cleaning LocatiO6S)---z-t-- <br /> ii. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> I Where Certified _ <br /> f Operator Name If <br /> I Plant Location <br /> Plant Capacity No.Units Served <br /> ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11Less Than 1,000 Sq.Ft., 13 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> certify that I have prepared ini;'.app!ication and tatthe work will bed ne in accordance with San Joaquin County <br /> 1hereby ce y - <br /> ordinances.state laws,and rules and r��s of the Sa q nn Local Health bistrict <br /> I � <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ON <br /> r�. ITE ❑ EACH ❑ Ja ry 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑'ANNUALLY ❑ PER UNIT ►/n PERS REMIT <br /> r BILLING REM ANCE $ AMOUNT DUE CHECKED . <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4413 0 a <br /> Date Receipt NO, Permit No. Is ante to Mailed Deli erect <br /> �- Reeved by r te01 E.HAZ LTON AYE..R.O.box 2009 ST CKTON A 95201 <br /> APPLICANT�RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PEA'1TfSER�ICES <br />