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Applications will Be Processed When 6dbmitled Properly Completed.Be Sure To Sign Tillie Appllaallon. t - <br /> �PPLICATiON <br /> ^ (For NonrTranslerabk,Rerocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> j C1 UQUIR WASTE { <br /> App1 n h(W. ... rryon b in tis I_n t `iurisdictionai area of th Jaaqu Local Health District 1 <br /> r 9usine ame{DBAowns � AddressFirm Partners.Addresses en ers ) <br /> Business Telephone No. T Q Emergency Telephone NO, i <br /> i Contractor Llcence No. <br /> L Applicants Name(Print) TIt1e Date <br /> •.;PRiI�t�laca.i�pptieable- gory(1-7)and Fill In Rte Regtd;ed Information . <br /> I. ❑ PUMPER:V£HICLE-PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For,July-4s1ltine k IR Disposal&tes <br /> Deefjp{,in(�.lekerv�."Co16i'1" -- - ' <br /> rlal NO.' ' `•�•. � CAL.License No. GAL.LICCRse Renewal No- <br /> CaPa�'ci(yY=* +-•- Gal.,Weights S Manure No. r, <br /> f5uipment Parking AddreBs_ <br /> 2-d1 niwpeh VAAD., <br /> For July t, June 3D,19- <br /> No. <br /> 9 No.of Vehicles Stored <br /> -No.of Chemical Toilets Stored ) ; <br /> 3. 11 PERCOLATION TEST <br /> R.S.or R.C.E Name R.S'ar R.C.E.No. I <br /> Test L Ion + Test Datl%Mnne - <br /> rl�t <br /> 4. IKSANITA'noN PE �' 1 <br /> Job Addr ocat!on _ <br /> owner - dQress - <br /> L3SEPTIC TAN ❑CESSPOOL 8'EEACONG•FIELD ©'S15EPAGE PIT ©PACKAGE PLANT' <br /> ❑PERMANENT ❑TEMPORARY ❑ NEW -&-REPAIR <br /> L ❑CHEMICAL TOILETS For July 1,-June 30,19T?'-. �7'•t + <br /> Type Construction DlaposawSite�• <br /> No.of Units Equipment Storege/ iGI;ed,g Location(s) <br /> S. ❑PACKAGE TREATMENT PLANT For July 1,-June 3aj 9 <br /> Operator Name _ Where Certified <br /> Plant Location <br /> Plant Capacity ,' No: nits Served = ' <br /> 7. ❑LAUNDRY For July 1,-June 30,19 • �" ' <br /> SIZE: ❑Less Then 1.0W Sq.Ft., ❑Mate Than 1.OW L <br /> ❑DRY k'LEANING,Chemicals Used/Amount/Mo. <br /> a[!`acr7•[c•e.Gr. edert'rAf¢naturaeeni'tcaihr foan7.±rl�:"iteRl, t;3tr '; • - <br /> !asuthmanse;a�!oyP[umt vu3iCr!iJµertr:!e:i s:om;:Fn;etl;,n{eVrc olCh;o..ti � ret ofthewo-rkforwhlch thispermit Isissved.fshalfr l empioyclry person <br /> CaRlrnt[ar'a h:+inp ur.uh:Lnirncsin;l 61;1100, •cii:l:m her-!rrJxhan ' <br /> Employ PersaesI cer:I'v,ht;irI the <br /> ;us.^dSu:aCrem;.!!s W,�lp^r.-aSMnlms_y;e;,:,yf6 iia.' Pcr!er^Ianca rl a!9v:erk ler TlhlCh:h:S p•rri'?e'ts?ay.I shall' <br /> I hereby Certify that I have prepared this application and.that the work will be done in accordance with San Joaquin Coun.jr I '1 <br /> ordinances,state laws,and les and reg on of^the San Joaquin Local Health District. <br /> J 1 <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> A <br /> Fee is Due:Ll-ANNUALLY ❑PER UNIT ❑PEa&TET Q EACH ❑JAnuery 1 a R---1 BV J-nu 31 t7 Joy 1 d Rcspl.en B7 Juh 31 <br /> elD'ATEa <br /> REMITTAN1rI, S RLCK , <br /> BASE EXPLANATION DATE REMITTED' AMOUNT DUE ,cAHMOON <br /> 1 <br /> FEE <br /> LESS <br /> PRORATION <br /> PPENALTY ; <br /> - r <br /> OTHER J/ • { <br /> DTHEaSS <br /> { i <br /> ._ APPLICANT-1IETI"ALL CORES TLc eN71aOMMlN7LL NluTll PEM1rcIaeaYlCLa .-_.-... list e.H^nLTON Atli_r.0-ew SOOs 87001[7011,G efirial .. <br /> NOTEXTPAGE <br />