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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. 3 <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE � <br /> Application AE <br /> e t rry o iness In the jurisdictional area of the San Joaquin Local Health District <br /> Add rens <br /> Jill <br /> �Business Name (DBA) <br /> a Owner' <br /> Address <br /> u Firm Partners,Addresses and Telephone Numbers Emergency Telephone No. <br /> nBusiness Telephone No. Il <br /> �. <br /> contractor Licence No. Title Date— "Jill <br /> t� <br /> Applicants Name(Print) .0 <br /> Please check Applicable Category(1-7)and Fill in the Required Informal IVn` <br /> 1. ❑ PUMPER VEHICLE PERMIT IREGISTRATION(FOR EACH VEHICLE) <br /> For Juiy 1, June 30,19 Disposal Sites <br /> Description(Make/Yr.,Color) II i <br /> � CAL.License Renewal No. <br /> Serial No. �• CAL. License Na. <br /> D <br /> Capacity ;ll Gat.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, <br /> No.of Vehicles Stored r <br /> No.of Chemical Toilets Stored <br /> u 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S.or R.C.E.Name <br /> Test Date/Time <br /> Test Location <br /> 1 <br /> j ❑ SANITATION PERMIiAJ <br /> T j <br /> 3 Job Address/Coca ion <br /> Owner % .00 - Address <br /> ,..,� ❑'PACKAGE PLANT <br /> 9d•S£PTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0 REPAIR <br /> ❑ CHEMICAL TOILETS For uty 1,-June 30, 19 <br /> ype Construction Disposal Site <br /> No.a#Units u• Equipment Storage/Cleaning Location(s)_ d <br /> 4 6. [3 PACKAGE TREATMENT <br /> PLANT for July 1,-June 30,19 *' • ' .' to <br /> I Where Certified s <br /> c Operator Name <br /> Plant Location' ~ i' <br /> - <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June-3Q•19_• - �- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000-Sq. Ft, y <br /> Ji- 0 DRY CLEANING,Chemicals Used/Amount/Mo. 'Y <br /> I hereby certify that I': armee p"r� ared'ttii5 appiic�tt25h yna-tliat'the work will be done in acxordanco'with San Joaquin County <br /> ordinances,state laws;;and rules ar .re gu ions of the San Joaquin Local Health District- <br /> APPLICANTS SIGIVATUREX - <br /> f{{\[ � . ` .rte..-.;+T 'w•,.�•+esw��-�w+•v �L 4 <br /> FdR DEPARTMENT USE ONLY <br /> + , Jit 1&Received By July 31 <br /> Fee Is Due:D ANNUALLY PER.UNIT ❑ PER SITE ❑ EACH January 1&Received, January 31 - ❑ y RE1iy11T <br /> SICCING REMITTANCE EAMOUNT DUE CHECKED <br /> BASE ` EXPLANATION DATE DATE REMITTED AMOUNT, <br /> 4 <br /> FEE <br /> k <br /> LESS ` <br /> PRORATION <br /> I! PLUS <br /> wPENALTY r <br /> OTHER <br /> a OTHER •a�a• _ ��} .� .. <br /> tz_ it s Mailed Delivered ( <br /> Receipt No. Permit No.- Issue.ee Date _ <br /> Received by Data _.. . <br /> r .1b01 E.Ftp2ELTON AYE.,PA•Bos-2if0®• S>fOCKTON,C7► x <br /> a <br /> APPLICANT—RETURN ALL COPIES Tlp:. -ENVIRONMENTAL HEALTH PERMI7ISERYICES <br />