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nun-nansfefaufe, nevucnme,anu auspeuuaun SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ,J I <br /> r, LIQUID WASTE <br /> Application is here b ode to carryon business in the jurisdictional area of thep5an J aquin Local Health Dis i t �1r�� <br /> F Business Name (DBA) �Q IS .SQIVf*��G Address /•�r l ` d S� 44 �lSr2� <br /> Owner Address <br /> M'Firm Partners, Addresses and Tele one Num ers <br /> aBusiness Telephone No. 07 3 Emergency Telephone No. <br /> Contractor Licence No. <br /> —Applicants Name (Print) Title 4431 Date Z d <br /> Please check Applicable Category (1-7) and Fill in the Required Information - <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> 'Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> ila Equipment Parking Address <br /> 2. ❑ PUMPER YARD \\ <br /> For July 1, June 30, 19 y <br /> .No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERM �'rk� <br /> Job LQiL lon SS I�f A� Y)A/ [\ <br /> r.Owne ,9,r Address <br /> SEPTIC TANK 13 -CESSPOOL Va LEACHING FIELD %SEEPAGEPIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY LKNEW ❑ REPAIR ; ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 9a <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,"June 30, 19, <br /> �Operator.Name Where Certified <br /> Plant Location (/ <br /> Plant Capacity No. Units Served <br /> y,7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 1 <br /> ❑ DRY CLEANING, Chemicals•Used/Amount/Mo. <br /> e <br /> r <br /> I hereby certify that I have prepared this application,-ging that the work Will be done in accordance with San Joaquin County <br /> r ordinances,%state laws,and rules and reg lotions of San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X Y L <br /> FORbEPARTMENT USE ONLY - <br /> Fee IS Dae: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE- ❑ EACH ❑ January 1 &Received By January 31 ❑July 1 6.Received,By"July 31 <br /> Y REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DA`fE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> _ sf <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS t/ <br /> PENALTY O <br /> OTHER <br /> OTHER <br /> 11110 <br /> Receiv,ld by pate Receipt No. Permit No, IssuartcMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Be.2009 STOCKTON,CA 95201 <br />