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1 <br /> V <br /> 60 <br /> APPLICATION <br /> ` (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> LIQUID WASTE <br /> LApplicatio,( is err,y made to carry onkusiness in the jurisdictional area of the San Jo�quin Local Health District <br /> N Business Name IDEA) 1J fJ I/Af/^I S{� �' ,o ti S ZAIC Address 1o� ISax JH C ` ` 0 • <br /> i Owner Address . <br /> a <br /> IV 2_Firm Partners, Addresses.and Telephone Numbers <br /> Y a Business Telephone No. 44 9 fa 0 7 Emergency Telephone No. <br /> Contractor Licence No. { <br /> L Applicants Name (Print) T Title SSF'/lSr rQL Data — 8-7 <br /> 17 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 6. i. I] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> 110 Serial No. CAL. License No. CAL. License Renewal No. -F <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> a <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 <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> ` 4. 0 SANITATION PERMIT J <br /> Job Address/Location 141AIr 51 <br /> ,� <br /> Owner 20hr // QA, >¢' �.0 f Address _ <br /> 29 SEPTIC TANK CESSPOOL X LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> 9 PERMANENT O TEMPORARY 0 NEW El REPAIR � OTHER <br /> _ s. I] CHEMICAL TOILETS For July 1,-June 30, 19 <br /> t Type Construction Disposal Site <br /> I•a No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. I] PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> - Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> V <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 /> LAPPLICANT'S SIGNATURE X f:V a*_ <br /> 6. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0.PER SITE ❑-EACH ❑ January 1&Received By January 31 ❑ July 1 &ReceiveddEB1y July 31 <br /> E <br /> %BASEEXPLANATION BILLING REMITTANCE S AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> P LESS <br /> ♦ PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br />