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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> a (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made tQ carry on business in the jurisdictional area of the San Joaquin Local Health DisIct <br /> r /� <br /> Bl:siness - ame (D A) Wn Address <br /> Owner_ 16►�5_ (�YL- Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. _meq'769.A _. Emergency Telephone No.5-0A4• <br /> Contractor Licence No. UA. Z�9—rr1-2Z7 <br /> t Applicants Name (Print) Q� Pn _ .._ Title _0L_MY__ Date!< 2 <br /> Please check Applicable Category (1-7) and Flit 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 /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. '�(PERCOLATIO TE T 2 <br /> R.S. or R.C.E. Name �_ uI1 _ l R.S. or R.C.E. <br /> No. C. G <br /> Test Location� 'S_ c 14yetiLpy, cl�. �/_►colTest Date/Timet�S�1ur <br /> L �1 �1 <br /> 4. ❑ SANITATION PERMIT S� a� 1� P' ° ih`j °Pp�'"1"�• "'��b 1�`Gy i3-l�qZ <br /> Job Address/Location <br /> Owner __ Address11 SEPTIC SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ 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 /> Plant Location ._ <br /> ----------------------------------- — <br /> Plant Capacity No. Units Served _ <br /> 7. ❑ 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/AmountJMo. <br /> �-e rG -A <br /> I hereby certify that I h e p epare this plication and that the work will be do ' accordan h San aquin County <br /> ordinances, state laws nd u es e I ions of the San Joaquin Local Health � ri t. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janu ryTl ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S OUNT DUE CHECKED <br /> — <br /> DATE DATE F <br /> I,?VjrM TAA AMOUNT <br /> FEE ,// <br /> LESS <br /> PRORATION <br /> PLUS — --- — — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit No Issuance Date Mailed Delivered <br />