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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. i <br /> APPLICATION <br /> a (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ica' is hereby rnad to car on busiWss in Jh un lictionalareaof SagJoa in Local_H�ea �istrict <br /> Address <br /> a dusin ame(DBA <br /> Address - <br /> L) Firm Partners,Addresses and Telephon Num ers <br /> aBusiness Telephone No. _ - Emergency Telephone No. <br /> Contractor Licence No. <br /> L <br /> Applicants Name(Print) Title Date ` <br /> ..Please check Applicable Cat (1-T)and,Flll�in the R uired Information K <br /> C d-+a1-.+'[:] PUMPER.VEHICLE,PERMIT REGISTRATION(FOR EACH VEHICLE) 1 r <br /> For'July-1; ' June 30f 19__ - Disposal Sites <br /> } *-•t.�q •; C <br /> Descnptlon(Make/Yr.;•Color)� <br /> CAL. License No. _ CAL.License Renewal No. <br /> Capacity "Gal.,Weights�&Measures No. <br /> �!'Equipment•Parkitlg Address' ,; <br /> 2. ❑ PUMPER YARD <br /> For lul 1, _ ._ Juge 30,19 <br /> Y <br /> No.of VehiclesStored No.of Chemical Toilets Stored ! t <br /> 3. ❑ PERCOILATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location! i I <br /> wn � aest Date <br /> /Time <br /> � <br /> qq <br /> 4. �„ SAO � E D F <br /> V <br /> Job Addr s/Lctio �/ <br /> Owner.. ✓ <br /> i <br /> Address <br /> Lel SEPTIC TANK IJ CE POOL,. 11LEACHING.FIELD El SEEPAGE PIT CKAG rL NT{ ' { <br /> [YpERMANEIVT &fiEMPORARY !❑ NEW ,f�tom ” W-VrPAIR ` R „� �ti► <br /> S. ❑ CHEMICAL TOILETS For July 1, June 30, 19'• <br /> ype Construction �^" ! c. 1 "✓r Disposal Site '-f ! _ t <br /> t <br /> No.of Units _Equipmen--$torage/Cleaning LocaAtion(s) r <br /> 6. 13 PACKAGE TREATMENT PLANT F(�mJu <br /> ly t,"`June 30, 19 y'�� 1 1 ' a <br /> r ;., / I Where Certified <br /> or Name <br /> Operat ) <br /> Plant Location - <br /> Plant Capacity, �146.Unitg:Served <br /> F <br /> 7. 11 LAUNDRY For July 1,-June 30, 19 ' <br /> SIZE: 13 Less Than1700 Sq Ft., ❑ More Th,,,4.000 Stl?Et. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> llftw ;ownertvffcansedggenYsx*rratrrec9rtWwathetov;ting:"(certili6atfntheperfortranceofthework for whichthis.permitisissued�, ,Ishall not employanyperson__D <br /> In succi manner as to hecoirl subject to vrarkntane Canpcnw itln iara� ! i ! <br /> Contractor'„ or sulr-convaeHng s;Mf 123.rr. cerzr.q!ek 'v'l:tkti.: i Car;?',r t"'a" the p2rfoi,i:I C^o,IhP m;fk for which.1hir,lierinit is issued•I Shall <br /> t g•1y1L'�{'I)•.^ISG.;_..:iblts`i;i I„:.Z+i::,.. # � 1 <br /> t 3. _ 7 � <br /> 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,a d rul�sand re�ttl �ttheS�,alfnJoaquin Local Health District. <br /> ! , <br /> APPLICANT'S#SIGNATURE X - <br /> �' .,. I.:-..rte;,,.-t �.�:���Ss.�Ayw1...`� -C,_a.. �s�. •.:+y .. .. , <br /> • ,.•.,, -� ---- •q.• -�.+..._._...tFOR E'PEPARTMENT USE ONLY- <br /> -4. <br /> NLY- � <br /> 'tea } <br /> Fee Is Due:�_ANNUALLy ❑ PERUNIT PER SIT ; ❑ EACH © January i 8 Reeved By January 37 ❑July 1 d ReCci1 RFJv11TuSY 31 <br /> •• .�+' ._• .. _ <br /> $•ASE \ EJtPL-ANATIO. •BILLING REMITTANCE . f 'AMOUNT DU CHECKED <br /> DATE DATE RE{MITTE – OUNT <br /> OX <br /> l FEE +�L. �.•� + w ..4' ! Q �' ��� <br /> !;�• <br /> r LESSIir <br /> PRORATION <br /> PENALTY } t- 1 ... <br /> OTHERi .. <br /> 60 <br /> 71— <br /> 07d-by ..� Darr.' Receipe No. - Permit No. ssuanc Date Mailed - Delivered <br /> P.O.•Sw-Z009 <br /> APPLICANT—RETUR42 COPJES TO ENVIRONMENTALMFALTH'PERMIT/SERVICES_.,.._ �"-tBt11'E:'NAZELTON`AVE; � KT�ON CA 96101 <br />