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Applications Will Be Processed When Submitted Property Completea. Ise sure lu-u ^rr•• <br /> ° APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <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) <br /> 14P/J!�2 I S SANS Address pial BeX /�S�O S7 'rf1 9t2C�/ <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> 5.a <br /> Business Telephone No. Emergency Telephone No. <br /> -j Contractor Licence No. :5 171 Al Date <br /> L Applicants Name (Print) Title <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 /> Description(Make/Yr., Color) CAL. Lio::nse Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 12. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> t No. of Chemical Toilets Stored <br />�+ 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E: No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time Q <br /> 4. 0 SANITATION PERMIT A-.a <br /> Job Address/Location sTL5?79 <br /> Owner FgZp h� _� E��4 •� Address © 0 PACKAGE PLANT <br /> ❑ SEPTIC TANK 13 CESSPOOL Df LEACHING FIELD SEEPAGE PIT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> have prepared this application and that the work will bd`f Io e in accordance with San Joaquin County <br /> I hereby certify that I p p <br /> ordinances, state laws, and rules and regulations of the uin Localalt istrict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEP RTME USE ONLY <br /> ❑ January 1 &Received By January 31 El 1 &Received By July 31 <br /> fi• Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ REMIT <br /> BASE EXPLANATION BILLIN REMITTANCE $ AMOUNT DUE CHECKED <br /> DA PATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S n t -7 <br /> Dat eceipt N Permit�� Issua ce Date Mailed eliver' a r� <br /> Received by t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Dox 2009 STOCK O 5 <br />