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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application..; <br /> i <br /> ~ APPLICATION '4 <br />} _ (For Non-Transferable,Revocable, and Suspendable) r <br />[ SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> j Al A-/P <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Age" Address fl '� <br /> I i Owner �, Address Y <br /> a .l <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 40- e-0 Emergency Telephone No. <br /> Contractor Licence No. og-5-43`�3 <br /> s Applicants Name (Print) Title C57`/s�A7tt� Date. -7!7 Y' <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 . Disposal Sites <br /> t Description(Make/Yr., Color) <br /> Serial No. .Fir CAL: License No. CAL. License Renewal No. <br /> Capacity :i�' Gal., Weights & Measures No. <br /> o Equipment Parking Address <br /> 2.ti❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored �M <br /> 3. ❑ PERCOLATION TEST Y <br /> k R.S. or R.C.E. Name R.S. or R.C.E. No. r <br /> Test Location i� Test Date/Time <br /> 4. A SANITATION PERMIT- it <br /> Job Address/Location _ L � <br /> Owner SAN TcpAQu�.r/ ASS�t/ Fa,� ,�E7�4��6D dA dress' a E L A fi <br /> �y SEPTIC TANK- CESSPOOL LEACHING FIELD ,SEEPAGE PIT ❑ PACKAGE PLANT <br /> IGAPERMANENT ❑ TEMPORARY X NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS ForlJuly 1, -June 30, 19 <br /> Type Construction �1 Disposal Site <br /> No. of Units i�, Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Operator Name Where Certified <br /> f <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Jhune 30, 19 <br /> ' SIZE: ❑ Less Than 1,000 Sq.'�Ft., ❑ More Than 1,000 Sq. Ft. <br /> i <br /> ❑ DRY CLEANING, Chemicals Uslled/Amount/Mo. <br /> L <br /> r � <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County j <br /> ordinances, state laws,t nd rules and regulations of the S uln`Local Health District. <br /> APPLICANT'S SIGNATURE X� ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY III ❑ PER UNIT ff PER 517E ❑ EACH ❑ January 1 &Received By January-31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING �REfv11TTANCE $ <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> :ill DATE DATE REIED AMOUNT <br /> x FEE 5,�, / <br /> LESS Li <br /> PRORATION ) <br /> PLUS <br /> PENALTY ` <br /> OTHER <br /> r OTHER I \ <br /> -73 q�_. �C <br /> Received by Date Receipt No Permit No Issuance Date Mailed Deliv ed <br /> APPL4CANT—RETURN'ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009- STO _TO;IRS ` <br /> 7 <br />