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i <br /> Appltct:;ions Will Be Processed When Submitted Property compieiea.Be Sure To Sign The Appticatlon. <br /> APPLICATION <br /> (For Nan-Transferable,Revocable,and Suspendsole) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Appticatior Is hereby made to grry n bus, ess in the juris tionat area of the San Joa uin Local Health Dlstri <br /> t r c� � ��,Address' d ff <br /> n Business NamCA)— �� <br /> Addless— S� , <br /> Firm Partners,Addresses and Telephone Nt3mbers <br /> a `y G' J � U.1� Emergency Telephone No. <br /> �. $ Business Tel Na. -- <br /> Cont actor Liconce No. 2 L 2 <br /> Applicants Name(Print) Title Dale- 3 <br /> Please ehec! Applicable Calego (1-7)and€it!ie th pee+ulred lnformatlon t t. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOA EACH VEHICLE) <br /> For July 1, June 30,19 4 Disposal Sites <br /> - Description(Make/Yr.,Color) <br /> Si91 No _ -- ; <br /> CAL.License No. CAL.License Renewal NO <br /> erf 'se <br /> Capacity Gal.,Weights&,Measures No. <br /> ` Equipment Parking'Address_ <br /> :-2-. ❑ PUMPER YARD <br /> For July 1; June 30, <br /> No.of Vehicles.Stored. ` <br /> No.of Ch of <br /> Stored <br /> 3:'❑ PERCOLATION TEST rf { <br /> R.S.or R.C.E.No: `F' <br /> s :R.S.or R.C.E.Name - <br /> -r -Test Lo +on'_ "_ — --- Test Date,rime { <br /> 4. 11►,SANITATION PER,%1IT <br /> Job.Address/Locatior. (I 10 p F 1 <br /> Ow�iAddresS' IJPACKAGE PLANT- <br /> LIF SEPTIC TANK ❑ CESSPOOL' IJ <br /> FIELDSEEPAGE PlT © OTHER <br /> ❑ PERMANENT. © TEMPORARY NEW Q REPAIR <br /> 7.5 ❑ CHEMICAL TOILE $ For July 1,-June 30, 19 <br /> ;. <br /> Disposal Site r <br /> Type Construction... --- _ <br /> I Equipment Slorage/Cleaning Location(,;I_ <br /> No.o.Units <br /> ❑ PACKAGE TREATMENT PLANT For July i,-June 30, 19_ Where Certified <br /> -r. Operator Name <br /> s Plant Location —_--. <br /> No.Units Served <br /> Plant Capacity J <br /> J F 4. <br /> 7: ❑ LAUNDRY For July 1,-June 30, 18 — : <br /> ❑ More Than 1,000 Sq.Ft. <br /> SIZE. 0 Less Than 1,000 Sa•Ft.. <br /> aF DRY CLEANING.Chem - C <br /> icals UsedlAmounVMo. <br /> LP- <br /> ❑ <br /> Hemeo.�yefp�p�ansedepen:-S�Igr.a7utoteftH'es:l'Jtottowlnry:' 'tG�r�rtel7l1h�N-JA fcrwtuththis permit 15l55u-d,tstWlnit employ a(lypGrs L . <br /> -. in such taaarw_T as:o become schiev..o wrf{ma:i rprpr^sdtit,ts tzvs of l;alrf �i::�' - , <br /> Com*srtor's !tiring or sub-eontrKling signature carUfies the foBo.anp. `t cettify ti:at is,It:e pertoir..arce at the work tet w hith[his permit 15 i;5[:'ed;1 shall <br /> em�ldy,�crsans sutrztt to vrotkmasi s rompfrmriva taws of tali?oraia: <br /> 3 : hereby certi[y_ihat i have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state taws,and rule and regulations of the San Joaquin Local Health District. I <br /> f. <br /> APPLICANTS SIGNATURE X-����--- <br /> FOR DEPARTMENT USE ONLY <br /> d 13Y <br /> w, _ <br /> Fee is Due.❑ 4NNUJ LLY t� <br /> PEA UNIT ❑PER SIT'_ ❑EACH ❑ Jal.wry?4�d Recewed 9y JanWry 7t ❑JvM f d Rete REMITuy]T <br /> BILLING _REMITTANCE .k S AMOUNT DUCKED ] <br /> RASE I EXPLANATION DATE DATE' REMITTED -AL10UNi' <br /> I f� <br /> -. <br /> FEE-'• i ,> .,..f I ter'-' -`� I — -T_ n ,, <br /> , - <br /> ,� -PLUS <br /> a!; <br /> i OTHER 'l- <br /> . <br /> ,.OTHER <br /> ..--. _ ._-_.--RKe•PI N� Pe,m;1 No IISxMnu 9wte.�..�-,i;t�.l�d�' Delro.bq - <br /> APPLICANT-RETURN ALL COMIES TO: - EWARONIA01TAL HEALTH PERLIT+S£RYICES 5601E NAZELTON AIrE/-.P.O.em 100}:, 9TOCIrTOiN.CA l:10T <br />