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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT G� <br /> LIQUID WASTE <br /> A_/ °ApplicT' he;0made to carry OR business in the jurisdictional area of the San Joaquin Loth Healt 1 ict 4 s ' <br /> F Business Name (DBA Address - <br /> I a Owner __ Address _- <br /> Firm Partners,A dresses and Telephone NumbersCIL <br /> Business Telephone No. - �Q _- Emergency Telephone No. - <br /> I Contractor Licence No. --- - <br /> Applicants Name (Print) r Title Date <br /> Please check Applicable Catego6(1 ) and F in the Requir Information <br /> 1. 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30,'191 Disposal Sites - - -- <br /> i Description(Make/Yr.,Color)_+- "�� - -NN Y <br /> Serial No.. CAL. License No. s V - CAL License Renewal No. 'r r <br /> Capacity - Gal.,Weights & Measures No. Nk - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1', � -Jbne 30;19 <br /> No°of�Ve.hicles-Stored Rz <br /> No. of Chemical Toilets Stored "� 1 <br /> 3. 'O'PERCOLATION TEST <br /> 1 A R_0or R.-G.E.`No. <br /> R-S:or R.C.E.Name d t� y, . <br /> )- Test Location. —_. Test Date/Time �T _ <br /> 4. ❑ SANITATION PERMIT Q <br /> Job Address/Locati n. ._ <br /> z y{ <br /> Ow0 <br /> ner <br /> SEPTIC TANK ❑ CE SPOOL LEACHING FIELD ❑ ❑ PACKAGE`PLANT <br /> ERMANENT ❑ TEMPORARY NEW y�-� ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J e 30, 19I <br /> Type Construction Disposal Site . <br /> No.of Units -__ _ Equipment Storage/Cleaning Location(s) I <br /> 6. 1:1PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> r, Operator Name -- Where Certified <br /> { Plant Location <br /> t Plant Capacity "r _ No. Units Served} _ • <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than ti,000 Sq. F`'. _ l <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 11 - t - <br /> � <br /> r I hereby certify that I have prepared this applicatlon and that the work will�1e done in accor`ance with San�Ioaquin County a <br /> ordinances, state laws, and rules and rags Onsof the:Aan Joaqui ocal Health District. t t <br /> t APPLICANTS SIGNATU X <br /> j FOR DEPARTMENT USE O LY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PtH SI rE ❑ EACH J n ar 1 S Re<ewed By January 31 ❑ July 1 &Received By July 3' <br /> REMIT <br /> BASE EXPLANATION BILLING ANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE c�a LESS . <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER Z/ <br /> 1 <br /> OTHER <br /> 2-9 _ <br /> % Rwelved by Dale _ _ Receipt No Permit No. lisuarlce D' t7� Mailed Delivered <br /> i - ,yXP�PUCANT—RETURN ALL COPIES T0=ENVIRONMEN_TA4 HLALTH PERMITISERVICES ���1601 E.HAZELTON AVE.,P.O.Bol 2009 STOCKTON,'CA 9520/��`�-�''�•.+ <br />