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Applications Will Be Processed When Submlt(ed Properly�Compleled,Be Sure To Sign The Application, r <br /> -APPLICATION a ��• -- <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTALHEALTH PERMIT SEPTAGE • <br /> r' UQUIU WASTE <br /> q Application is-hereby made to carry on business in thejurisdlctional area of the San Joaquin Local Health District <br /> ausiness Name (DBA) Adtlress <br /> Owner IJs�r kG? iA1�1GJ Address I <br /> "Firm Partners,Addressee and Telephone Numbers <br /> a Business Telephone No, 47 R— (p J n Emergency Telephone No. <br /> a Contractor Licence No. ,,,, / <br /> L Applicants Name(Print) Title t�r�,� I'". <br /> Please check Applicable Category(1-7)and Pill In the Required Information Date <br /> 1, ❑ PUMPER VEHfCLE PERMIT REGISTRATION(FOR EACH VEHICLE) N <br /> For.July 1,_,June 30,;.19 Disposal Sites J, <br /> Description(Make/Yr.,Color)) ' .S - <br /> Serial No. CAL. license No. CAL.License Renewal No. <br /> Capacity Gal„Weights&Measures No. <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30,19 <br /> No.of Vehicles Stored " <br /> t� <br /> ,No..of Chemical Toilets Stored �I <br /> R <br /> 3, 13 PERCOLATION TEST • �,,, ` <br /> R.S.Or A.C.E.Name - <br /> TR.S.or R.C.E.No, <br /> est ocatlon Test Date/Time <br /> 4. JP,SANITATION PERMIT 11-5 2-0 t: <br /> Job Address/Locatlon <br /> Owner / PSY L1 r-Yy1L'} J gadress 1�4 k2. .4ld6rr ��r'� nyl <br /> 0 SEPTIC TANK ❑ CESSPOOL - ❑"LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT d,TEMPORARY.0INEW El REPAIR 13 OTHER <br /> S. ❑ CHEMICAL TO1LE'f$ For July 1;-June 30,19. , <br /> s Construction j- Disposal Site <br /> ,..,.of Units Equipment Storage/Cleaning Location(s) <br /> S. 0 PACKAGE TREATMENT PLANT.,,For July 1,•-.June 30,19 <br /> Operator Name ' <br /> Plant Location <br /> Where Certified r <br /> "Plant Capacity A%Served - <br /> 7. ❑ LAUNDRY For July 1,-June 30,19 - <br /> -SIZE 0 Less Than 1,000 Sq, Ft., ❑ More Than X1,000 Sq. FL} <br /> ❑ DRY CLEANING,Chemicals Used/AmounUMo. _ y 7 <br /> i • II <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County t <br /> ordinances,state lawsn rules end rp9ations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY 7 <br /> Fee is DUs:❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re00iVed Ry January 31 Q July 1 a RaayiveoBy July 31 <br /> BASE EXPLANATION BILLING REMITTANCE g REMIT <br /> DATE OAT REMITTED AMOUNT DUE CHEORED ` <br /> FEE _ AMOUNT <br /> LESS J <br /> PRORATION , <br /> PLUS- <br /> PENALTY <br /> OTHER <br /> �`' OTNER <br /> n t <br /> � �d )) <br /> R8c61vy4,by Date ?$`� Receipt No. : armll <br /> APPLICANT—RETURN AL come To: ''ENVIRONMENTAL HEALTH PERMITISERVien 16Di F,19SSU3 L O ate P.O.aoa7ape STO� ivered CA V$pat v <br />