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APPLICATION <br /> (For' -Transferable, Revocable,and Suspendable) SEPTAGE <br /> - EIVORONMENTAL 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 /> f;, r - - Al .�_Address /?-y= <br /> Hess Name (DBA) A (.� t :f• -�i� t �' :*-� <br /> er Address <br /> Partners, Addresses and Telephone Numbers _ <br /> Riess Telephone No. G>�Z�-7 Emergency Telephone No. <br /> tractor Licence No. <br /> 'icants Name (Print) _ 1 �C�7 LJQ7 Title rme � Date <br /> se check Applicable Category(1-7)and Fill in the Required Information <br /> :1 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) f <br /> July 1, June 30, 19 Disposal Sites _ \ J <br /> Iription(Make/Yr., Color} <br /> al No. CAL.License No_ CAL_ License ReneW4I No. <br /> acity Gal.,Weights&Measures No. <br /> pment Parking Address <br /> :1 PUMPER YARD <br /> July 1• June 30, 19 <br /> of Vehicles Stored 1 <br /> of Chemical Toilets Stored t <br /> PERCOLATION TEST <br /> or R.C,E_Name R.S.or R.C.E.No. <br /> Location Test DatelTime <br /> V SANITATION PERMIT <br /> Address/Location L 30 1 • LI1 e 'e-0;'3 <br /> ler 7-CA) S f,19d'E5 --- Address <br /> 'EPTIC TANK ❑ CESSPOOL - LE/fiCHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> 3ERMANENT ❑ TEMPORARY �_ NEW ❑ REPAIR OTHER <br /> 3 CHEMICAL TOILETS For July 1,-June-30. 19 d <br /> e Construction Disposal Site <br /> of Units Equipment Storage/Cleaning Location(s) <br /> :1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> rator Name Where Certified <br /> it Location <br /> t Capacity No_ Units Served <br /> LAUNDRY For July 1,-June 30. 19 �!- <br /> _. ❑ Less Than 1.000 Sq. Ft.. ❑ More Than 1.000 Sq_ Ft_ �c <br /> )RY CLEANING,Chemicals Used/Amount/MO. L <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 rules and regulations a San Joaquin Local Health District. j <br /> LlCANT'S 51GNATUflE X _ �� Ar — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 16 Recened By July 31 <br /> REMIT <br /> BILLING REMITTANCE - $8ASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKEDAW <br /> AMOUNT �V <br /> FEE <br /> — — -- --- <br /> $ � <br /> PROLESC>a\- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -, , <br />