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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. :+ <br /> APPLICATION <br /> Non-Transferable, Revocable, and Suspendab <br /> 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 /> ,Business Name (DBA) T>A> S s Address. Se AOX �. <br /> z Owner Address <br /> w c) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 60 7 - Emergency telephone No. <br /> 1 Contractor Licence No. 3 <br /> Applicants Name (Print) r Title EST/ir�1ATrJ7� Date — <br /> M <br /> Please check'Applicable Category (:1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMITREGISTRATION (FOR EACH VEHICLE) <br /> y For July 1, June 30, 19 11 Disposal Sites <br /> Description(Make/Yr., Color) �� 1 <br /> Serial No. J. CAL. License No. CAL. License Renewal No. "? <br /> Capacity sir Gal., Weights & Measures No. <br /> Equipment Parking Address �M <br /> 2. ❑ PUMPER YARD <br /> For July 1; June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I s <br /> •l <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. i <br /> Test Location Test Date/Time <br /> 4. J4 SANITATION PERMIT <br /> Job Address/Location <br /> Address E .STAG <br /> k O ner �-'� N� e� C] PACKAGE PLAN ` <br /> RSEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For my 1,-June 30, 19 k <br />'; Type Construction SII Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br />` 6. ❑ PACKAGE TREATMENT PIfANT For July 1, -June 30, 19 <br /> Operator Name Where Certified �N <br /> Plant Location <br /> Plant Capacity 14 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. ft., El More Than 1,000 Sq. Ft. <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f S <br /> l 1 hereby certify that I la ave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,.,and rules and regulations of th an Joaq in Local Health District. <br /> APPLICANT'S SIGNATURE X ` Sr(9i/6 CNK Ok .� LcL12�llZt_= / <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE; EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE '] REMITTED AMOUNT <br /> I FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER II <br /> I !!! - <br /> OTHER III <br /> _ /� /�7 <br /> t <br /> Received by - Date- Receipt No. Pe� r - lss anc Date Mailed Teliv�er <br /> APPLICANT—RETURN ALL COPIIES TO: ENVIRONMENTAL.HEALTH PERMITAERVICES - 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCK ON,CA 5201 <br />