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Applications Will Be"Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> APPLICATION <br /> } (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL'HEALTH PERMIT <br /> A LIQUID WASTE <br /> tkla�io�`` is herebyR de to carry on business in the jurisdictional area of the San Joaquin Local Health District,, <br /> H <br /> Business�SName (D } I I7 Y�2riL�l ..Address 3 1 2 Lf-)�P_� r (� y 9/2-l/ l�L <br /> aOwner F'�i22t/ . .... - Address 57,4,vy �! <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ��b I & g3 Emergency Telephone No. 2- <br /> Contractor <br /> Contractor Licence No. >9 <br /> LApplicants Name (Print) Title ou��a .- -_.---._ Date__J�"./D"gl._- e <br /> Please check Applicable Category(1-7)and Fill In the Required Information in V <br /> t. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June-30, 19 -Disposal Sites <br /> Description(Make/Yr.,Color) w . <br /> Serial No. CAL. License No. CAL. License Renewal No. I <br /> Capacity Gal., Weights &Measures No. ± <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 } <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored � <br /> _ _ <br /> 3. 11PERCOLATION TEST 4. 4, + � <br /> R.S. or R.C.E. Name ► R.S. or R.C.E. No. <br /> Test 1,ocation I Test Date/Time <br /> 4.2'- SANITATION PERMIT <br /> Job Address/Location 41 ' t:rJ�s?� clostb I-1,19le- L, 9,573 7 L <br /> Own i-, ' 2 . Address 3 <br /> ��PTIC TANK ❑'CESSPOOL f 21 ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ° <br /> Ia PERMANENT ❑ TEMPORARY t � NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, t9. <br /> Type Construction Disposal Site I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> Operator Name s e Certified <br /> Plant Location <br /> .Plant CapacityNo. Units Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 r F" ^ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- f , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws nd rules ani <br /> n regu tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE a { <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT L7 PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> E REMIT <br /> BILLING t REMITTANCE $ <br /> BASF EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE,, REMITTED AMOUNT <br /> EEE s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER- <br /> 7 <br /> OTHER <br /> Ig <br /> Received y ' Date I Receipt No. Permit No. Issuance Date Mailed a were / <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.90■2009 STOCK N,CAJw_.� <br />