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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppucauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,P-ERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> mBusiness Name (DBA)_�-a /s' °ems Address e, -:!5EZ7 <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> tel` -�g// Emergency Telephone No. <br /> 0. Business Telephone No. ,�� r <br /> Contractor Licence No. .• f1 / <br /> Applicants Name (Print) <br /> ! Title _ _ Date <br /> Please check Applicable Category.(1-7)and Fill,ln the Required Information , 1 ri.; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i� 0 <br /> For July 1, June 30, 19— — Disposal Sites - - - - - <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No:- T <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address' - <br /> 2. ❑ PUMPER YARD ,err I I <br /> For July 1, June 30, 19 <br /> No. of Vehicles-Stored <br /> No. of Chemical Toilets Stored f --- <br /> 3. ❑ PERCOLATION TEST' i ) <br /> R.S. or R.C.E. Name *. "t4. '• "" �` 'R.S. or R-.C.E.No.� - - <br /> Test Location <br /> + st ate/Time <br /> II ,4T 6 N Ursa . .. . <br /> 4. g SANITATION PERMIT !� <br /> Job Address/Location l, R - <br /> GsI � <br /> Owner BEI.+I'.4/ Y� E/? ..v!.. i� -•� -. Address , <br /> SEPTIC TANK ElCESSPOOL LEACHING FIELD : El SEEPAGE PIT, ❑ PACKAGE'PLANT{ <br /> A rr�`<: �'lflF9���..1 .�'.' <br /> PERMANENT ❑ TEMPORffRY` OTHER�'•�-�NEW.� �. "t ��' •'❑-REPAIR F i <br /> 5. ❑ CHEMICAL TOILETS For Julyti, -June 30, 19— <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> ` + <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 N <br /> Operator Name Where Certified <br /> .r <br /> Plant Location <br /> No. Units Served ' �` <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 x <br /> SIZE: ❑ Less Than 1.000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a + — <br /> 1 ,� f° ) <br /> a r j <br /> .I hereby certify?that I have prepared:this application-and that the work will be done in accordance with San Joaquin County <br /> �► <br /> ordinances, state laws, and rules and regulations of t e Joaquin Local Health District. f <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ 1u1,1T&Received By July 31 <br /> REMIT <br /> �(BASE EXPLANATION I KILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> k EX.PLANATION DATE E REMITTED AMOUNT <br /> G - - <br /> FEE <br /> LESS <br /> PRORATION } <br /> PENPLUS <br /> ALTY - e. t <br /> OTHER <br /> f <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered STOGKTON,CA 95201 <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br />