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�. APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) 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 /> NBusiness Name (DBA) }`��`�`� �` —Address <br /> i Owner_ f.��-� — Address - <br /> 1 Firm Partners, Addresses and Telephone Numbers , <br /> aBusiness Telephone No. 5� y�6J- ---- - Emergency Telephone No. — <br /> Contractor Licence No. �/ Date — - <br /> L Applicants Name (Print)— �zL1�`�/'.-„CCL��-�--- Title _- � - "r - - - <br /> Please check Applicable Category (1-7)and Fill.in the Required Information <br /> 1, ❑ PUMPER VEHI6LE PERM PT-FItGiSTRATION (FOR EACH VEHICLE) <br /> For July 1,_- —June 30, 19 _ Disposal Sites <br /> Description(Make/Yr.,Color)_ CAL. License Renewal No. r — <br /> Serial No. CAL. License No. — <br /> Capacity: Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD C <br /> For July 1,_ June 30, 19 . <br /> No-of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name _ <br /> Test Date[Time— <br /> Test Location <br /> 4. ❑ SANITATION PERMIT ' l c 10oi <br /> Job Address/Location _ `�f •J _����%�' Y �" � — <br /> OwnerfAddress— <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT <br /> 13 PACKAGE PLANT <br /> ❑ NEW ❑ REPAIR ❑ OTHER <br /> PERMANENT ❑ TEMPORARY <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19_ V <br /> Type Construction Disposal Site _ r <br /> No. of Units — — Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - <br /> � - Where Certified — <br /> Operator Name — --�-- <br /> Plant Location - <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— — <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. E <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeewnerorficerreeda9en•'^'19n+hrnfww,w tFefetlowin3:'l*.P�itythatinttrepertOrmanceofihewtxkfatwhichthispeFmitisis•lled.ish�!'rntc ,pinvanyCer^ C <br /> I. <br /> in-such manner as to temm..s ” ct tr,��.Jr,:, 3r,s aatn? ^.'on'aws of Ca`iforttia`certily that in the performance of the v;C.tk',cr ti;'°rh ti�.->?erl' ,.. .;d. <br /> coritractor's Kiri" O; S4F-G07+1 Ct^_:;•Rl (.•t)r.,jh;.: Lfr�JlCE! Che f0110vWn9' l <br /> eiT.Ploy pefsons$affect to wurkludu s WIIIPV,"I, )a IdNs of Gafifanla" <br /> I hereby certify that 1 have prepared this application and that the work will be-done in accordance with San Joaquin County <br /> District- <br /> ordinances, state laws, and rules an regulations of the San Joaquin Local Health District. —x—z <br /> APPLICANT'S SIGNATURE X <br /> FOR.DEPARTMENT USE ONLY <br /> anuary 31 Juiy 7 &Recew <br /> Fee Is Due-. 0 ANNUALLY ❑ PER UNIT C3 PER 517E ❑ EACH ❑ January 1&Received By J ❑ gBy REMIT July 3l <br /> ' I HILL.ING- REMITTANCE �b AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMVTTEP AMOUNT <br /> I � q <br /> s . < i <br /> FEE <br /> 41 <br /> PRORATION <br /> PLUS 1 �� <br /> PENALTY <br /> OTHER !+ — <br /> OTHER <br /> -.. <br /> Date � Receipt No. Permit No. I arae D to Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 S70CKTON,GA 95201 — <br />