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_ <br /> Applications Will Be Processed When-Su6mitted Properly Completed. Be Sure To Sign The Application. ` <br /> APPLICATION <br /> n.. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> t <br /> Application is hereby made to carry on bu iness in the jurisdictional area of the San Joaquin Local Health District <br /> mBusiness Name (DBA) �t}�✓ Address A".x ! - <br /> COwner Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. `c" 9ep d _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) L4 990 D Title 7-11"A 7Z7� Date 14`I 7 <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., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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 y <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location I/OPCr/ i_ eiiL�3T�__ <br /> Owner A"&OWA IC Address 7,667 I-S0Abf_1e_bW",e Ir?� S i C 7►��.,t� ��3.[t� <br /> C1SEPTIC TANK llCESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER `h <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 - <br /> Operator Name Where Certified C <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> w: SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count f <br /> ordinances, state laws, and rules and regulations of the San Jqu local Health District. (�� <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPAR MENT USE ONLY <br /> ee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> } <br /> FEE VLESS <br /> .� <br /> PRORATION +a T t <br /> PLUS <br /> PENALTY <br /> OTHER \ - <br /> } <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1P,01 E.HAZELTON AVE.,P.q.aox 009h�T�O,C TON,CA�}5201 � <br /> -M - dk_6 IY 'T n �J '->7 _J 1f <br />