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APPLICATION <br /> SEPTAGE <br /> (For Non-Transferable, Revocable,and Suspendable <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereba'made to carry on busi es�Address <br /> ris 'ctional area of the San Joaquin Local Health Dy�triCt ---- <br /> Add rens �J <br /> Business Name (DBA) i Owner- <br /> Firm Partners. Addresses and Telephone Numbers Emergency Telephone No. —J ) <br /> - �-$' i a s — --- <br /> Business Telephone No. 2 �/ <br /> Contractor Licence No._ Title �'`L� Date_—��= <br /> --s— <br /> Applicants Name (Print) <br /> Please check Appiicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 Disposal Site }'s <br /> For July 1, ---June - *— - . -4, <br /> Description(Make[Yr.,Color) CAL. License No. CAL. License Renewal No. <br /> " <br /> Serial No. <br /> Gal., Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD <br /> For July 1,_ June 30, 19 'E " !s <br /> No. of Vehicles Stored . w <br /> t � ` <br /> No. of Chemical Toilets Stored �+ �� .► F� <br /> 3 ❑ PERCOLATION TEST ! R.S. or R.C.E.No. i <br /> R.S.or R-C.E. Name Test Date/Time i <br /> Test Lp6ation <br /> 4. SANITATION PERMIT eiel <br /> Job Address/Loc tion Addrest��EAGEPIT <br /> / <br /> Owner Vo <br /> ri- ❑ P KAGE PLANT <br /> Q S PT{C TANK ESSP OL ❑ LEACHING FIELD R HER � <br /> [B-'P ❑ TEMPORARY 11 NEW REPAIR <br /> L7 PERMANENT i.. <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t;y Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) r _ <br /> d �' Q <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19� ,Where Certified o <br /> Operator Name T _ _ <br /> Plant LocationNo. Units Served „ <br /> 9. <br /> Plant Capacity- j , <br /> 7, ❑'LAUNDRY For-July 1, -June 30, 19 1 <br /> i <br /> E. <br /> 0-Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- <br /> SIZE. <br /> t. <br /> SIZ <br /> ❑ DRY CLEANING,.Chemlcals Used/Amount/Mo. <br /> 1 <br /> 1' <br /> C that l ave prepared this application and that the work will be done in accordance with San Joaquin County <br /> y 1 hereby certify �_'and'r'ules <br /> " an Joaquin Local Health District.ordinances, state lad regulations oft' 'APPLICANT'S SIGNATUREX : "� <br /> FOR DEPARTMENT USE ONLY � July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ <br /> ❑ PER SITE EACH REMITTANCEJanuart &Received REMIT <br /> By January 3tAMOUNT DUE CHECKED <br /> 4 BILLING DATE REMITTED AMOUNT <br /> BASE EXPLANATION DATE <br /> FEE �t +` �I� z <br /> LESS <br /> + PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> - <br /> ssuanc Dat ailed Delivered <br /> Receipt No. Fermi! <br />