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Applications Will Be Processed When Submitted Properly Completed. Be FSureToSign 1neAPP <br /> t i <br /> APPLICATION <br /> (For Non-Transferable;Revocable, and Suspenda6 e SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to ca" <br /> on business in the jurisdictional area of the San Joaquin-Local Health District <br /> �. Address <br /> Business Name (DBA) . - . <br /> Address �.�.. . <br /> a Owner R <br /> Firm Partners, Addresses andTelephone mNu+7ibe}s Emergency Telephone No. <br /> CL <br /> 4 Business Telephone No. i <br /> Contractor Licence No. <br /> Title(E jDate <br /> L Applicants Name(Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information 9 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 v <br /> For July 1, June 30, 19 - - -Disposal Sites <br /> Description(Make/Yr.,Cotor) T - _- - <br /> CAL. License Renewal NoA - a -- <br /> Serial No.� CAL. License Nod <br /> Capacity Gal.,Weights &Measures No. I <br /> Equipment Parking Address + <br /> 2. ❑ PUMPER YARD <br /> � 1 <br /> Forbuly 1, * June 30, 19 <br /> No. of Vehicles 5foe, o, <br /> w i y'rj L <br /> No. of Chemical Soilets SID. <br /> I 3. ❑ PERCOLATION TEST i,' X.C. <br /> �., A $,% Y'- R.S. or R.C.E"IVo. <br /> `R:S.$r R.C:E. Name - _. ..-- <br /> ' Test Date/Time _ <br /> Test_L5ation <br /> 4. L� SANiTATION•PERMIT - - •�- I <br /> Job AddreWlbcation 2-0 <br /> Address <br /> Owner i LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> '❑,SEPTIC TANK ❑ CESSPOOL +� <br /> C+�'•1;EPAIR,', gym. OTHER • �d� t �z9�I.� <br /> 9'-rERMANEN7 ❑ TEMPORARY <br /> NEW <br /> +�._ .x .a <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site' E- 1 <br /> t <br /> I. Equipment Storage/Cleaning Location(s) <br /> Noo.of Units i <br /> . <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ) t* <br /> ' i Where Certified <br /> Operator Name y ? <br /> Plant Location t <br /> No. Units Served t <br /> Plant Capacity <br /> ❑ June 30, 19 <br /> ' <br /> A <br /> 7. LAUNDRY For July 1, - ,• S�� <br /> } SIZE: ❑ Less Than 1,000 Sq. Ft., 11 More Than 1,000'Sq. FS. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo, t s ) <br /> c <br /> f <br /> i hereby certify that-I have prepared this.applicaiiandon that the work`w I'be done in accordance with San Joaquin County <br /> #,-6rdlnancessstate laws, s and ceg ion's of the Joaqui ocaiy- alth District- <br /> APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY , t <br /> Y = <br /> Fee IS Due-. ❑ ANNUALLY El PER UNIT PER SITE © EACH ❑ January 1 &Received By January 31 July 1 &ReceivedREMIT <br /> 31 <br /> .._. �— <br /> i �BILLING'~�' REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 5 J K <br /> FEE <br /> LESS <br /> PRORATION' <br /> q� :PLUS ��, �' - ��,-�R,.= -� .,,.�."-. ...er+w.�.'�-a-'�."'�"„'`"�:.��'-.•.a . <br /> PENALTY• - - _ <br /> r OTHER J�N alb <br /> OTHER �J , <br /> • S <br /> i Permit No. issuance Date ed Delivered <br /> Received by u.,�Qate ReceipS No. <br /> a 1601 E.HAZELTON AVE.,P.OAB 2009 STOGNTON,GA 952 <br /> I, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES i 'i, <br />