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�Pr„c-....•,� ..,., ..e r,....c=acv ..,,�,. wvn. acv r vYcur r np•cmu. vc omv ,u myu ,nc npRna.a.wu. <br /> APPLICATION <br /> ` (For Non-Transferable, Revocable, and Suspendable) SEPTAGE s <br /> ENVIRONMENTAL HEALTH PERMIT ) <br /> LIQUID WASTE 1 <br /> Applicatio is err,y made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> �- r � � NArriSl So..s Trtic Address Po i�x /mss-o -v '? ars ' <br /> w Business Name (DBA) � - <br /> i Owner Address <br /> a <br /> u Firm Partners, Addresses and Telephone Numbers <br /> No 1 Business Telephone No. Z16 6 ' 9 12z0 7 Emergency Telephone No. <br /> a —4 4 <br /> �Contractor Licence No. .� v <br /> Applicants Name (Print) r Title f CT/iP)d TL�F Data�/ a -79 <br /> r 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 <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 /> V 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 <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> LTest Location Test Date/Time <br /> 4. C4 SANITATION PERMIT <br /> Job Addrre�ss/LL,ocation <br /> Owner �cnUf�l �O.V I' adz Address n K <br /> ` X SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> N PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> this Plant Location <br /> Plant Capacity No. Units Served <br /> 7. El LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �1r <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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C6l,� Y <br /> FOR DEPARTMENT USE ONLY <br /> [Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> ` DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> y� PRORATION _ <br /> PLUS J <br /> PENALTY <br /> OTHER \ <br /> OTHER <br /> to <br />