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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,. APPLICATION <br /> (For Non-Transferable; Revocable,and Sundable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMI-Ift- <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the'urisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) <br /> WOWS- eG Address '�--$© • &N �{� srVc ON <br /> i owner C G�ANC��uJOI� -' . _ Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness-Telephone No. 4--—4—.Cc�� —:Emergency Telephone No. <br /> Contractor Licence No. _a <br /> L Applicants Name {Print) �+`RAW CE v tv - Tit4e. ` �-S ; 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��- ' " .- Disposal Sites- <br /> De'scription <br /> ites-Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. d <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1', June 30, 19 <br /> No. of Vehicles Stored <br /> l No. of Chemical Toilets Stored <br /> 3. )(PERCOLATION TEST r� a s� <br /> R.S. or R.C.E. Name _ 4-. Cl v�!AOM W O N G- R.S. or R.C.E. No. <br /> Test Location I''3Q.i aa���� Test Date/Time e <br /> 4. ❑ SANITATION PERMIT -?jt�e_L MAP ®i — 1-7O a <br /> Job Address/Location <br /> Owner Address ` <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD © SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site - d <br /> -No. of Units Equipment Storage/Cleaning Location(s) f-=I- <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 t <br /> Operator Name Y. Where Certified <br /> .Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30; 19 1 <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 application and that the wor be done in accordance with San Joaquin'County <br /> ordinances, state laws, and rules and,regula o e n Joaquin o al alth District. <br /> APPLICANT'S SIGNATURE'X_ <br /> 06 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 &Received By January 31 ❑ July 1 &;Received By July-31 <br /> I i _ -- - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE -DATE- REMITTED _ AMOUNT <br /> FEEy <br /> LESS <br /> I PRORATION " W " <br /> PLUS - <br /> PENALTY <br />. - OTHER 2- <br /> OTHER.OTHER. <br /> Received by Date .Receipt No. Permit No. - Issuance Date 'Mailed Delivered <br /> . APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES t11601 F.HA2ELTON AV .,fO.86-x2009 S70GKTON,GA 95201 <br /> A w <br />