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� � .. <br /> �Applications Will Be Processed When SubAmPiiP`.'CAT'ONroperly PkeieBe <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 11111111'San11 a, i ''cal Health District KD�I C <br /> ]� Address 1 q G <br /> yBusiness Name (DBA) address /[ <br /> a Owner h'r! t I f >I J A o tri RU <br /> Firm Partners, Addresses and Tele hone Numb�rs Emergency Telephone No. <br /> aBusiness Telephone No. ill <br /> Contractor Licence No. a Title C t M #u' Date <br /> !L/— $O <br /> Applicants Name (Print) <br /> c L. <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR SACS VEHICLE) <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <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 R.S. or R.C.E.No. <br /> l R.S. or R.C.E.Name Test Date/Time <br />` Test Location <br /> 4. ❑ SANITATION PERMIT f 7 +L <br /> Job Address/Location �97`T 4/ U.�L_• V r <br /> jam; Address A <br /> Owner ❑ SEEPAGE PIT LEACHING ❑ PACKAGE PLANT 4(O + 30 9 IS <br /> ❑ NG FIELD xg ¢ <br /> 14 SEPTIC TANK ❑ CESSPOOL REPAIR C3 OTHER 'J <br /> 13 PERMANENT 1311 ► <br /> TEMPORARY NEW X <br /> g. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> CA <br /> I No. of Units Equipment Storage/Cleaning Locations) CA <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., r <br /> t ❑ DRY CLEANING, Chemicals Used/Amount/l <br /> f <br /> k <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul4hnregulations o e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> l FOR DEPARTMENT USE ONLY <br /> i REMIT <br /> i Fee I5 pUe: ❑ AN PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE S� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTi-IER ,a, � I <br /> C) 46 <br /> t Received kiy Dae Receipt No. <br /> tPermit No: Issu nce Date Mailed live d <br /> 1 APPLICANT;RET UR ALL COPIES Till ENVIRONMENTAL HEALTH PERMIT/SER <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOC 70N,CA 952 <br />