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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <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 /> OF `Address.J r' d <br /> �, Business Name (DBA) ,. .. �,4;. ,t - <br /> z Owner c -AddressCA <br /> �� <br /> Q _ - - ,. <br /> Firm Partners, Addresses and Telephone Numbers <br /> a- Business,,Telephone No. , J' 6 Emergency Telephone No. IF-318 3 S'9!A <br /> _J Contractor Licence No. <br /> a Applicants Name (Print) c o r �5 S$isL , Title . bate_�la <br /> L w <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 /> _ r <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 <br /> 2. ❑ PUMPER YARD T <br /> For July 1, June 30, 19 <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.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ ocation � -7l� } �d 1 E1rSt S'� _ �SGai�O n S 3d o <br /> Owner c-a 6 Address <br /> ❑ SEPTIC TANK. ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER p <br /> ' S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 . <br /> J <br /> Type Construction 'Disposal Site"�, ..__ <br /> No. of Units Equipment Storage/Cleaning'Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3Q"19 4111 <br /> Operator Name 1*=•,#+N\ Where Certified <br /> Plant Location l\ <br /> Plant Capacity No. Units.Served } �` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 't�;:'T • <br /> SIZE: - ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, CPI <br /> �1 <br /> ❑ QHY CLEANING, Chemicals Used/Amount/Mo. <br /> f?81i1 86'i;HlzFt?t)ic� �J�S3?� �q�'F§f R���Sit�gin��#,����rrt��i�wu:ra6 �sai #i t•!,�!'� � � ���t . <br /> 14-4411 Mgt @.Ri <br /> fig; `� (Bft� 1 r' §;.t3 ti9i tr rune s{gpaturr �aft,(ws the foll9vving; {cerir#y that in the peFt9�'zt ce Pf i,l a v 9fk �4@���� @F dtl <br /> I 19f w N01(hi5 P@Ft>1!t <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San JoagyrV70unty <br /> ordinances,state la d rules and regulations of the n Joaquin Local Health District. ✓ <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PERUNIT ❑ PER SITE ❑-EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - - REMIT <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION BILLING <br /> pQ DATE DATE REMITTED AMOUNT <br /> FEEINS <br /> r v <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER , <br /> OTHER ' <br /> Received by Date ceipt No. Permit NO. ' Issuanceto Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO A 95281 <br /> -+ c' <br />