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Applications Will Be Processed When Submitted Properly Completed. Be Sure 1 o mgrn 1 o—wR•tea•• <br /> oe APPLICATION <br /> ,I=— (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> l ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE _ <br /> Applicatio reby de to a on b ess in the jurisdictional area of the Saran oaWin�Qal HeatDjstrip��2r <br /> a Business N e (DBA) — Address / d <br /> aOwner,T Address <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. e <br /> Contractor Licence No. Title Date •2 - V <br /> Applicants Name (Print) a <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 04 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Vr., Color) CAL. License Renewal No. <br /> Serial No. __ CAL. License No. <br /> Capacity _ t Gal.,Weights &Measures No. <br /> Equipment Parking Address _ .� <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 y <br /> No. of Vehicles Stored .j_ <br /> No. of Chemical Toilets StoreO + <br /> 3, ❑ PERCOLATION TEST <br /> " R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name __ �.. Test Date/Time - <br /> Test Location p - <br /> A. ❑ SANITATION PERMIT 1 y Js <br /> Job Add ress/Loyetion <br /> n �q Address O <br /> Owner _�--- � ❑ ACKAGE PLANTfir- _ <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT OTHER S6w` <br /> g.PERMANENT ❑ TEMPOFffARY AW NEW 11 REPAIR <br /> 5. ❑ CHEMICAL TOILETS For[July 1, -June 30, 19 <br /> ` Type Construction 11 Disposal Site <br /> IF No. of Units •� Equipment Storage/Cleaning Location(s) <br /> i <br /> .I 6. ❑ PACKAGE TREATMENTPLANT For July 1, -June 30, 19 Where Certified <br /> 1 Operator Name <br /> i Plant Location _ <br /> F No. Units Served c� <br /> l Plant Capacity ( <br /> 7. ❑ LAUNDRY For July 1, -Jlune 30, 19 <br /> SIZE: ❑ Less Than 1.000 SgAt.. 11More Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. --- <br /> I hereby certify that have prepared t is a tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws.antl as o ation f the San Joe Loca Health District. <br /> •_ APPLICANT'S SIGNATURE x / <br /> ( FOR DEPARTMENT USE ONLY <br /> n�vary 31 ❑ July 1 L Received By July 31 <br /> Fee Is Due: 13 ANNUALLY i [3 PER UNIT [3 PER SITE 11 EACH ❑danuery I d Rece_wa REMIT <br /> BILLING REMITTAN AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE ITTED AMOUNT <br /> i <br /> 1 <br /> FEE <br /> PRORATION <br /> PLUS <br /> PENALTY • <br /> OTHER <br /> OTHER 3D <br /> Recei t No. PoERrmiNo <br /> 1 uance ate 1iME DelCKTO <br /> ReceWeE by DY1e __ __ _-..........uP ru uIAl TR►ERMITBEIIYICES ta01 E.HAZELTOM AVE.,P.O.!ov 2009 STOGKTON,CA 15201— <br />