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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' r`+ APPLICATION <br /> Y (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat' is hefJ eby made to/c rry on business in the jurisdictional area of the San Jo a in L cal H th DWI,ct <br /> OF Business a e (DBA) /ip Ie/G����D -Address <br /> aOwners=, <br /> wner ` _o Address 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. qV,2 17 6 Q Emergency Telephone No. <br /> -J Contractor Licence No.�-� <br /> Applicants Name(Print) e 1s Title ..44a'-,rem - Hate /5' <br /> V <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) tT�4 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity - Gal.,Weights &Measures No. <br /> Equipment Parking Address—._ _ r <br /> 2. ❑ PUMPER YARD a � <br /> For July 1, June 30, 19 - - ��---�---� --- —� ---- --- ^ - �� <br /> r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location r. Test Date/Time <br /> 4. X SANITATION PERMIT-i YP A ! \ <br /> Job Addres Location / 4 _ <br /> Owner — 1� • Pa}s Address <br /> SEPTIC TANK 1 ❑ CESSOOL LEACHING FIELD -0-SEEPAGE PIT ❑ PACKAGf PLAINT <br /> ❑ PERMANENTI ❑ TEMPORARY ❑ NEW 11 'REPAIR'- E] OTHER <br /> 5. 11CHEMICAL:TOIL_ETS For JC y.1, -June 30, 19 <br /> Type Construction + �i _ _ Disposal Site r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 "01 ► <br /> Operator Name -- Where Certified 1 <br /> Plant Location 1 t <br /> Plant Capacity No. Units-Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 , <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ` <br /> t <br /> C I <br /> I M <br /> I hereby certify thEtt I h p red i applic on nd h the work will be done in accordance with San Joaquin County <br /> ordinances, state laws and ru and ations of th S uin Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE X <br /> I <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> HEC ED <br /> I DATE DATE REMITTED - AMOUNT <br /> FEE j <br /> LESS F <br /> PRORATION <br /> i <br /> PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issu rice D to Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A(/f7/fes %;CKTiN,CA 952 <br />