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Y ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I (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 ItLe San Joaquin Local Health District ... <br /> Business Name (DBA) LTJ -xAddress <br /> Owner - <br /> Address. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business"Telephone No. — Emergency Telephone No. r <br /> Contractor Licence No. r <br /> L Applicants Name(Print) -,&. rL Title <br /> Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information _ a <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; a 30, 19 = - Disposal Sites <br /> Description(Make/Yr., Colors <br /> Serial No. CAL..Xicense=Ni'r'' '5'�F # rt . "CAL. License;Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD16­1 <br /> For July 1, June 30, 19 1 .i <br /> No. of Vehicles Stored- _ - <br /> f! <br /> No. of Chemical Toilets Stored i <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> t f <br /> Tescation - Test Date/Time a t <br /> 4. ^SANITATION PERMIT <br /> Job Addr ss/Location A► 1 <br /> O hert C..V/4 <br /> ��.,,// _ pAddress �I.r,�, <br /> EPTIC TANK ❑ CESSPOOLJ�L��EACH.1f�G FIELDEEPAGE PIT ❑ PACKAGE PLAN-ift` �)Z—PERMANENT ❑ TEMPORARY -NEW �ZQE. EPAIR ❑ OTHER <br /> .5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 •( "�-� <br /> Type 6onstruction i Disposal Site � . <br /> No. of Units t <br /> Equipment Storage/Cleaning Location($) !E <br /> ,6. ❑iPACKAGE,TREATMENT PLANT For July 1, -June 30, 19 <br /> k i- a + <br /> Operatoi Name' <br /> �; ,� "«;�-� Where Certified <br /> Plant Location # <br /> Plant Capacity r Nv. Units Served f) <br /> 7: O.LAUNDRY For July 1, -June 30, 19J------------- <br /> SIZE,1 ❑ Less Thar)l1,000 Sq. Ft., ElMore Than 1,000 Sq. Ft. <br /> ❑ DR jJ {1) Jmc�als Used/Amount/Mo, _ ,, v <br /> Iln such marit1QS tti f I+- 4 <br /> �'T *� s �av w FNF i 4^+ In4 fc� Ir+�tta trire�e fo �`rlarw ��, `^ ��r <br /> i !i n, rtFTtCOfti7L'V,'. L1 -Fn t = 4is pCrrtii i,isstled,l s' e. '� t <br /> ;>r;!fi{TCf 4Y,tic:Ikii11S�P' • n{6�any}?CrSt7it �( <br /> I hereby certify that 1 :have repared this application and that the wor will be done in accordance with-San Jbe�i;§ 6aggt+ys"ail- w <br /> ordinances, state laws,'a ru s and regul "ons of the. Joaq 'n al He th District. <br /> __� s s AA <br /> 14 <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY �R„ <br /> Fee is Due: ❑ ANNUALLY I PER UNIT, PER SITE ❑ EACH ❑ January 1 &ReceivedSBy January 31 ❑ JIi#y 1 &Received By July 31 <br /> BASES 4:LANATI,ONJBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> nATE DATE REMITTED AMOUNT"FEE <br /> LESS <br /> PRORATION <br /> PLUS E v •i. <br /> PENALTY x _ + r '°"`� t <br /> OTHER _. > `•�4F�, .t s �` <br /> OTHER. tix i <br /> -5=l7-= <br /> Received by Date Receipt No, Permit Noor ISSLIance Daie Mailed <br /> Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMI-OSERVICES` 1601 E.HAZELTON AVE.,p O.Box 2409 STOCK ON,CA 9 201 <br />