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Applicallons Will Be Proensed When Submitted Property Completed.Be Sure To Sipa The Appl"tk m <br /> 7 APPLICATION a <br /> j1' � (far Non-Transferable.Revocable,and SuSPOndable) ,SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT (30t <br /> LIQUID WASTE <br /> r <br /> Applicati hereby mad to ca on bus^leas in ju edict' na res of the S oa u Local Healt I <br /> W <br /> business td =-IQ -s _�^ dre_ Address--/Owner Firm Partners Addresses and a Numbers <br /> Business Telephone No. b. Emergency Telephone No. -- - <br /> k <br /> Contractor Licence No. �- <br /> L'ApPlicants Name iPrint) Z �_ ---Title Date <br /> Please eMdt Appftasble Category P(I-7) d FIS In Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE)\ <br /> For Judy 1, June 30.19 Disposal Sitesi.---- - — <br /> 4:� - <br /> Description(Maker.,Cp10f) ( <br /> Seticf NO. CAL.Lk waw No. -- -�- --CAL.License Rar+ewal No- <br /> cffipi�ity -- Gat.,Weights A Measures No. - - - - <br /> Equipment Parking Address <br /> j ❑'PAMPER YARD �. <br /> For July:1, June 30,19 W <br /> w No.df VeNlsles S-0`0 - <br /> No.of Chemical Toilets Stored - <br /> S• ❑ PERCOLATION TEST <br /> R S.or R.C.E.Name R.S.or H.C.E.No. <br /> Test 4 tion IA Test Dateftime_ <br /> A.' Id SANITATION r <br /> f ` <br /> Job Add L ati <br /> Owner. AddI�EPAIR <br /> t ❑ PACKAGE PLANT <br /> ❑.f�EPTIC TANK ❑ CESSPOOL, t EACMING FIELDAGE PITPERMANENT ❑ TEMPORARY O NEW a OTHER <br /> !i ❑ CHEMIC/'.L TOILETS,;;For July 1, June 30, 19- f <br /> Type <br /> Construction <br /> No..of Unita Equipment Sleaning Location(s)- <br /> ❑ PACKAGE TREATMENT PLAIT For JWy 1.Tune 30,19 <br /> Y=. Operator NameWhere Codified <br /> " Plant to flim -- <br /> ion <br /> Piarit CapecHll �_ No Units Served <br /> y.. ❑ LAUNDRY. For July 1,-June 30.19 <br /> SIZE: ❑ Less Then 1,000 Sq.Ft., ❑ More Than 1,000 Sq,Ft., F <br /> ❑DRY CLEANING.Chemicals UNSWAmount/Mo. - - <br /> YY, <br /> S <br /> }� 1 hereby certify that I have Prepared this application and that the work will be done in accordance with San Joaquin County <br /> t'. ordinances,state laws.a rules�nr"7 regulations of the San Joaquiny�ocal Ith Distrix, <br /> 1. APPLICANT'S SIGNATURE X - � -- -t - - - <br /> FOR DEPARTMENT US <br /> Fee to Duo:❑ ANNUALLT ❑PER UNIT PER SITE EACH pry t A Rccmred ny January 3t ❑July 1 a Recpwm Ry July 3t <br /> __ -- - - T - - - <br /> - BASE EMANATION BILLING ! RE TANCE 1 AMOUNT DUE ._._ CHECKED <br /> _.. ..__..... _.._ ..»._.... ATE.• DATE+ - ---_pEMIttED AMQUNT <br /> FEE <br /> LESS V <br /> PRORATION <br /> PLUS <br /> OTHER + —_ -w__-... ... .-- .. _ _ _-_•. -.. ._ <br /> OVHEP <br /> C�S�I iso IRdOld <br /> ..__ .Ant..e bi_._ . �... _ ...... <br /> GCtvpd ey.�,._...,..___.---Dila.__..-._ g -........_.......v ._...Prr+.it Nn ii irHorde <br /> AOtCAMT--II[TURM ALL C0"%6 TO' pNYIlrTAL HE11L <br /> HEALTH MIRMTlgElltnCIS im1 E.NAlTOM AMC..Peca.i700► 9TOCRT CA SMIPL <br />