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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION Q <br /> O (For Non-Transferable, Revocable,and Suspendable) SEPTAGE # <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl is n is h .re ade to carry on s e ss the urisdictional area of the San Joaquin Local Health District -rte 1r L <br /> r Business Name {DBA) D �� _ , � Address T 10 �.5 <br /> Address <br /> z Owner s. <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. M- 06/� Emergency Telephone No. . <br /> %3 <br /> Contractor Licence No. <br /> LApplican s Name (Pring).= <br /> y Title Date <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 I Disposal Sites <br /> Description(Make/Yr.,Color) - !f <br /> I CAL. License No. CAL, License Renewal No. <br /> Serial No. .� <br /> x- ! <br /> Capacity Gal.,Weights & Measures No <br /> Equipment Parking Addre-"ess�v I <br /> I 2. ❑ PUMPER YARD C <br /> 10 1 r' <br /> For July 1, June 30, 19 �", . ; <br /> No. of Vehicles Stored 't"s <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST a ,1 t "�+�,\,jR S'or�R.C.E.No. <br /> R.S. or R.C.E. Name - <br /> Test Location <br /> �r 1 F <br /> 4. l� SANITATION PERMIT <br /> Job Address/Location �c� tr a <br /> i Owner ® Addreqs�s /s� <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING.FIELDy ) SEEPAGE PIT ❑ PACKAGE�PLANT <br /> * t�? ❑ OTHER `A 'C• �.._ Ca '�.^"_: <br />( PERMANENT ❑ TEMPORARY.�3 NEW- t ❑ RE 41I <br /> 5. ❑ CHEMICAL TOILETS For July 1, Jjilne 30, 19 17 <br /> Type Construction Disposal Site <br /> q P g <br /> No. of Units <br /> E ui ment Stora a/Cleaning Location(s) <br /> 6. 13PACKAGE TREATMENT PLANT 'For July 1, -June 30, 19 ' <br /> Operator Name stn.,��� .� ., •`-�S n' •"• - Where Certified <br /> N <br /> Plant Location <br /> No. Units-Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 301;19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ,�,-,, <br /> ! ❑ DRY CLEANING, Chemicals Used/Amount/Mo. + ` <br /> I hereby certify that I have prepared this applicatioand that the work will be done In accordance with San Joaquin County <br /> ordinances, state laws, a s and regulation!�of th S n Joaquin Local Health District-- <br /> APPLICANT'S SIGNATURE <br /> !i <br /> I <br /> yFOR''DEP7IRTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [:]'July t &Received By July 31 <br /> j# �...... . - REMIT <br /> BASE ; ' EXPLANATION BILLING REMITTANCE AMOUNT DUES CHECKED - <br /> TDATE D TE REMITTED n„ �.- + AMOUNT <br /> ' FEE <br /> r <br /> LESS I <br /> PRORATION <br /> . r <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> 1 OTHER <br /> Received by Date Receipt No, Permit O.. Issuance Date Mailed. Delivered <br /> •- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES X1601-E..HAZELTON AVE.,P.O.Box 2009 STOGK70N,CA 85261 <br />