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� - Applications Will Be Processed When Submitted Properly Completed. Ise sure to al9n ..o....... <br /> int,^Yvn . \ <br /> rte. APPLICATION <br /> i. (For Non-Transferable,Revocable,and Suspendabie) - SEPTAGE , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business In the jurisdictional area of the San Joaquin Local Health District <br /> fusiness Name (DBA) AAelT' 'Oery s= SoN Address <br /> pp' /3eX l�t7 /� oq�i�sTO <br /> is ZOwner SCP /SIiYT�Jb/Yy- Atldress <br /> S2,Firm Partners,Addresses and TelephonOilUmbers ^ <br /> ( nr-A - rI��''� Emergency Telephone No. <br /> 'a Business Telephone No. <br /> Contractor Licence No. 1 G b-S9G <br /> i L Applicants Name(Print) Title Date <br /> i Please check Applicable Category(1-7)and Fill In the Required Information - <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> I For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> I <br /> Serial No. CAL.License No. CAL.License Renewal No. <br /> Capacity _ Gat.,Weights&Measures No. <br /> t Equipment Parking Address _ Y <br /> 2. ❑ PUMPER YARD <br /> ( For July 1, June 30,19 <br /> ( No.of Vehicles Stored <br /> 1 No.of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST . <br /> R.S.or R.C.E.Name _ R.S.or P.C.E.No. - <br /> Test Location Test Date/Time Y <br /> 4. M SANITATION PERMIT <br /> Job Address/Location �8 76 '� 1��� O <br /> S Owner Fd Y.O+I/ 'drs Address '-5A^I t° <br /> 19 SEPTIC TANK (]'CESSPOOL O LEACHING FIELD ® SEEPAGE PiT Q PACKAGE PLANT <br /> 13-PERMANENT 13 TEMPORARY IN NEW REPAIR O OTHER <br /> 5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 od, <br /> •Type Construction I Disposal Site <br /> I N ,l <br /> o. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREAT14NT PLANT For July 1, -June 30. 19 <br /> Operator Name i Where Certified <br /> 1 Plant Location - - - <br /> No.Units Served <br /> Plant Capacity _ <br /> 7. 11 LAUNDRY For July 1,-June 30. 19 <br /> t SIZE' 0 Less Than 1,000 Sq. Ft., 111 0 More Than 1,000 Sq. Ft. <br /> _ <br /> 13 DRY CLEANING,Chemicals Used/AmounVMo. <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, ul and regulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 a Received By July 31_ <br /> REMIT <br /> eASE -{ EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> ' -1 <br /> FEE [ <br /> PESS <br /> RORATION + .. <br /> I PLUS <br /> PENALTY <br /> OTHER ` \- <br /> OTHER <br /> m 3 s I - <br /> Received by Date Receipt N0. Permit No. (HAZE a Mailed Delivered <br /> APPLICA —RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ . 1991£,HAZELTOP.O.Bo:9909 5?0CKT0N,CA:9$29t <br /> NT <br /> t( - <br />