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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 /> „r, Business Name (DBA) D-A PARR15HnCk4z•7�C- AddressP040 <br /> z Owner Address w + <br /> Firm Partners,.Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Emergency Telephone No. <br /> Contractor Licence No.__ _ �t►-� �" <br /> �Applicants Name (Print) Title ES-52Mft- A6=,_ QVK' Date I Z7`91 <br /> Please check Applicable Category(1-7)and Fill in the Required Information M1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19" Disposal Sites A... <br /> Description(Make/Yr., Color} <br /> Serial No. CAL. License No. CAL. License Renewal No.'. f t <br /> Capacity- Gal., Weights &Measures No. r <br /> Equipment Parking Address <br /> ,rte"d'_.. ., i -• I t..s.. �.,-!..,.w <br /> 2. ❑ PUMPER YARD <br /> For July 1, Julie 30, 19 j <br /> No. of Vehicles Stored.`3 <br /> No. of Chemical Toilets Stored <br /> ti <br /> 3. ❑ PERCOLATIONTEST <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/Location 23c?o73 FLOC)6 Ire-e4. L—IAJD_a:st, (341— <br /> owner 5!W RZ40MA 5CM.1939,WWO LP4J1D _°Eddress <br /> 0 5 PTIC TANK :11 CESSPOOL- CACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ©'PERMANENT &TEMPORARY 91-<EW ❑ REPAIR ❑ OTHER N <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 !11 . �.] <br /> Type Construction Disposal Site Co <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6" ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 VJ <br /> Operator Name -Where Certified <br /> Plant Location `h 1" <br /> Plant CapacityF - No. Units Served <br /> 7. ❑ LAUNDRY For Jbly 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 /> r ' <br /> I hereby certify that I hayp <br /> prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and gulati of the Joa uin Local Health District. <br /> APPLICANT'S SIGNATURE { <br /> - - FOR�*DEPSA`RTMENTIUSE ONLY - Y <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- j/ PER SITE• 0 EACH El January 1 &Received By Janu4ry 31 ❑ July 1 &Received By July 31' <br /> _ ii,'"'a'" i - f _REMIT . <br /> {{ BILLING REMITTANCE $ - <br /> " BASE EXPLANF�TION i AMOUNT DUE CHECKED <br /> F DATE DATE REMITTED AMOUNT <br /> r <br /> FEELESS <br /> ,� <br /> r-•y�.-�M y <br /> PRORATION " '•'�' `'<', ^-^ "•-•� "SAa+ <br /> PLUS <br /> PENALTY <br /> Ft'tian <br /> OTHER <br /> OTHER43. <br /> w.-. .s..y�.n, .r a.�. �.. .. �s.wr'>,._: � --..rrt /'� � l`�.�-*-.�./�. «..----..w.w.:....:...,��....r..:..r"r.-,•• .W. <br /> Received by Date Receipt No r Permit No s f -S �•I lauab e..Daate 1,.�ailed"'+ Del <br /> ivere <br /> APPLICANT=RETURN ALL COPIES TO:""'ENVIRONMENTAL HE0.LTfi PERMIT/SERVICES:.�ti:,"'".w --°1601 E.HA2ELTON AYE P.O.Baxp2009- STOCKY N,CA 95 1 <br /> S <br /> J <br />