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i J <br /> Applications Mlltl Be Processed When Submitted Properly Completed.8e Sure To SIP 171*APPOCSWAL <br /> APPLICATION <br /> (For Non-Transferable,Raeoc*W.and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WAETE <br /> ApplicaN a rgb�v m de to c3 On business in thg jurisdictional area of the _Joaquin J.p�1 Health Di3trio <br /> „Business Na (+D_BA)�Afl`�'��S k ��Ste" Address 2 O r.�+�i('ow+ Ryc <br /> Owner_ CA,161/C Address- <br /> Firm Partners.Addresses and Telephone Numbers - <br /> Business Telephone No.- Emergency Telephone No. <br /> �1 ConInWDr Licence No. <br /> Applicants Name(Print) — Title - Date <br /> Please chem*Applicable Category(1-7)and Fill to the Required Information <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For.,uly 1. June 30.It Disposal Sites <br /> Description(Make/Yr..Color)- -- - <br /> Serial No, CAL.License No. _- CAL.Licz-:e Renewal No. <br /> Capacity Gal_Weighta d Measures No. <br /> Egjlpment Parking rldre:ss <br /> 2. 0 PUMPER YARD <br /> For July 1. June 30, 14 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored_ — <br /> 3. ❑ PERCOLATION TEST <br /> Name <br /> R.S.or R.C.E. R.S.or R-C.E No. - <br /> Test Location Test Date/Time --- J" <br /> 4. ❑ SANITATIONPERMI03.5041t' iQd <br /> Job Address/Locatlon — <br /> OwnerAddress <br /> ®SEPTIC TANK ❑ CESSPOOL RL LEACHING FIELD ❑ SEEPAGE PIT 0 PACPLAGE ANT <br /> ER <br /> II PERMANENT ❑ TEMPORARY LJ NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1.-June 30. 14 _ X640 ��S'ep1Gc TA�Jc '�_ 9Q/ �rAts+ <br /> Type Construction- Disposal Site <br /> r . Equipment Store e/Cleaning Locations) <br /> • ' No.of Units �._.._�_-_.- R g <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1.-June 30. 19 Where Cert,W <br /> Operator Name T ry rv_ <br /> I Plant Location Na.ilnet!Serve. -- <br /> Plant Capacity <br /> f <br /> ❑ LAUNDRY For July 1.-June 30. 19 <br /> S <br /> SIZE: ❑ Less T.`.3n 1,000 Sq Ft.. C1 More Than 1.00.00 0 Sq.Ft. <br /> I ❑ DRY CLEANING,Chemicals Used/M+ount'MO. - <br /> t <br /> I hereby *emit;"hat I have prepared this application and that the wprt will be done in accordance with San Joaquin County <br /> ordinances,state taws, lesand regulations Of thefin Joaquin L,_1_81 Health District. <br /> M - -- - - <br /> APPLICANT'S SIGNATURE X - - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:O AuNt)At Ly ❑PER UMT _0 PEn i1TE F ❑EACH ❑ srw+_n it ❑July r A R&C"FN.rah V <br /> BILLING .�AVATTANCF � - f _—AM"T DUE C►,ECKEO <br /> SASE ExPLANATION t1ATE .DATE r+EUITTED AMOUNT-- <br /> FEE <br /> LESS <br /> PLUS <br /> OTHER <br /> OT—EA <br /> A r[A�rT-tlErltrttt AI L COMf TO: EHyyt0-W-TAL MMrN PEtnn7rfEtR•ri if MAZ[LT •O 64m 20w 1TOCt[TOrL to <br /> F <br />