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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -� n' APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) a SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatir- :;y madgejo_,arry on business in-the jurisdictional area of the San Joaquin Local Health "o " <br /> v;Business Name (DBA) -- Gov _ `Address. <br /> a Owner 1,6 <br /> D.G a r- T o9 8 el <br /> zi <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 1-2--3 — � Emergency Telephone No. <br /> Contractor Licence No. _ . +� '3 ' <br /> L Applicants Name (Print) rot: Title ''" ' Date — y 9– Z Q <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 - N <br /> f <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 <br /> For July 1, June 30, 19 r, <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.'ASANITATIO'N PERMIT <br /> Job Address/Location . i- <br /> O ner S <br /> SEPTIC TANK t C1 CESSPOOL'; XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ', ❑ 'IVEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1 -June 30, 19. <br /> Type Construction ,Disposal Site �[ <br /> No. of Units x!7h-Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT' For July 1, -June 30, 19 <br /> Operator Name s._ _ _ _ Where Certified _ +1 <br /> Plant Location 'F + <br /> Plant Capacity.-� � No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> iVll <br /> SIZE: ❑less Than 1,000 Sq. Ft., ❑ Morey Than 1,,000`Sq'Ft. <br /> ❑ DRY CLEANING, Chemicalsbsed/Amount/Mo. t <br /> �'I611tyr a ottiea� ai r'Ih. ;r 1 rt`ttshc3`�wir„:"t tr?if•//t*�-i;11`h I1Y'cr";I+£" Of the ork"anwhichthispermilisissued.[shall no,emp(o attyperson <br /> Ali, c C.tS;iip a �fitt;-l�§lv5 Irl fsetts+�'"sul ` .- � _ <br /> etttxameort:.hrcittg or. �t1iY-cdnCrR' lrtr.c aer t►re cc::Nir ' tlie, <vr ..b amity tEIM ittt0,e pertorinanCe of the v;3rk forwhich this permit is issue,I shall <br /> ��'0ak'it& e�4+nrt`f;A;YlA7�:131;�11S;G9R-:pF'l�7_llOFil,1UV'� 'C„uit.iit:,".. . <br /> hereby certify that l have prep a h' Ica nand that the work will be ne in accordance with San Joaquin County <br /> ordinances, state laws, and rul of the San Joaquin Local He t District. 1 1_ <br /> APPLICANT'S SIGNATURE <br /> { <br /> —1 FOR DEPARTMENT USE ONLY <br /> 1 <br /> �--� — U <br /> Fee Is Due: O ANNUALLY []"PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $.DATE DATE REMITTED �.- AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> q , <br /> r <br /> LESS t ,� <br /> PRORATION' <br /> PLUS <br /> PENALTY "'ter . .-•.�'.� .r(.- - 'first;-. __ J" ct yr.t,a o ., <br /> OTHER a=:Gr k") J-1�r�T (�.e!d._�- ��'1-Y+SI��� . 001 ^ <br /> OTHER J Z / �1fCh- w '� `� >✓4 L�1/�� lJ <br /> .- <br /> 2j- <br /> Received by Date f Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT— <br /> wrRETURN <br /> nnALL COPIES T : ENVIRONMEPTQrAL^�HEALTH P RMIT!$ERV S 1 1 E.HAZELT N AV Box 2009 STTOC�KTTONN,CA 95201 <br /> AJ�At_1�!•_w(�.r11�1 �� 7! d L►���....s.i.w,rLR <br />