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Applications Will Be Processed When Submitted ProperlyGompteteu. oC��« .., ,,,y,. •••- •-�,
<br /> APPLICATION
<br /> (N`,,don-Transferable, Revocable,and Suspendable, SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on usiness in the jurisdictional area of the San Joaquin Local Health District
<br /> T7 d _Px�YZ. k � � �_Address:���s,.0 I�'Se�•_ ���
<br /> Business Name (DBA}�
<br /> Owner Address
<br /> Firm Partners,Addresses and Telephone Numbers
<br /> — LD 7 Emergency Telephone No.
<br /> Business Telephone No,
<br /> Contractor Licence No. Date S Z"
<br /> Applicants Name (Print) 517 Title 1
<br /> Please check Applicable Category (1-7) and Fill in the Required Information oZ
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 Disposal Sites
<br /> Description(Make/Yr., Color) SAL�Llc�nse Renetival No.
<br /> Serial No. CAL.License 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 R.S. or R.C.E. No.
<br /> R.S. or R.C.E. Name
<br /> Test Date/Time
<br /> T st ocation
<br /> 4SANITATION PERMIT
<br /> Job Addre s/Locatio z•
<br /> Owner Address 1 •--
<br /> SEEPAGE PIT ❑ PACKAGE PLANT
<br /> ❑ SEPTIC TANK - CESSPOOL EACHING FIELD ❑ OTHER
<br /> PERMANENT 13 TEMPORARY ❑ NEW REPAIR
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Type Construction Disposal Site Iry
<br /> No. of Units Equipu nt Storage/Gleariirig Localtion(s) -
<br /> .'t . �. _
<br /> g. 1:1PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified .
<br /> Operator Name
<br /> Plant Location
<br /> No. Units Served
<br /> Plant Capacity
<br /> 7• ❑ LAUNDRY For July 1, -June 30, 19 ^r F
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> NG, Chemicals Used/Amount/Mo,
<br /> ❑ DRYCLEANI t/Mo .. ,.�, �.-�;:,�;f, r,� rT;t� �.I-'�'Inei�i*�lo',•a;�ype...- .
<br /> Homeownp.r or liza"ned
<br /> In SLCl1 It1r JN annel
<br /> !c - 1 rr
<br /> Contractor's hirirw or tt .
<br /> BRIp'Uypersons 5Ghi8L,WY.,:.�'...� .,G. �� .,.,,�..,.,I��ti.�:.i(,d'h]rnie..
<br /> I hereby certify that I hav epared this application and that the work will done in accq/ Rce with'Sa nounty
<br /> ordinances, state laws, ulat' of th a Joa i o I Ne h Distric
<br /> APPLICANT'S SIGNATURE X +
<br /> Y
<br /> kr
<br /> 0,611 b&ARTNENT USE ONLY t i
<br /> i
<br /> ❑
<br /> El SITE ❑ EACH, ❑ January 1 &Received 8y January 31 ❑ July 1 8 ReteiVR MylTul�31
<br /> Fee lk Due: 1:1 ANNUALLY PER UNIT
<br /> BILLING i REMITTANCE $ IAMOU�T DUE CI•.IECKED}
<br /> BASE EXPLANATION; DATE DATE RE TTED - AMOUNT I
<br /> FEE
<br /> LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY - _ .- ! .A
<br /> OTHER
<br /> OTHER
<br /> Sq !3`�
<br /> 1 rLA
<br /> Receipt No. Permit Na Issuance Date Mail Delivered
<br /> Received by Date -
<br /> APPLICANT-RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMlT1SEflV`CES' ^- y i44t E.HAZELTON-AVE.,P.Q.Bo>t 2409 yS70CNTON,CA M. -
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