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z <br /> t <br /> - � <br /> Applications Will Be Processed When Submitted Properly completes. ae ourw r� -,n - i <br /> .. ;; APPLICATION ; <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE ! <br /> ENVIRONMENTAL HEALTH PERMIT <br /> u4UID WASTE <br /> I Applicata Is h reby ade to carry on buss s in the jurisdictional area of the o for cal Health�� ��District � <br /> rBusiness Name(DBA) <br /> ��� rrtS^�� ��S s Address L.7Cu,] '� <br /> Address <br /> Ownev — <br /> Firm Partners, Addresses and-Tele hone liumbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> -J Contractor Licence No. Title --- Date - <br /> i a Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> h <br /> For July 1,__-June 30, 19 Disposal Sites - L� <br /> Description(Make/Yr.,Color)_- CAL. License Renewal No. <br /> I CAL. License No. W <br /> Serial No. - <br /> Capacity— Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD . . <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored <br /> t No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 11 R.S.or R.C.E. No. __.-- <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location _ <br /> 4_ K SANITATION PERMIT C, <br /> I Job Address/Loc lion �- <br /> Owner _ �C Address <br /> ❑ CESSPOOL LEACHING FIELD �J SEEPAGE PIT ❑ PACKAGE PLANT M <br /> �J SEPTIC TANK C1REPAIR ❑ OTHER <br /> PERMANENT ❑ TEMPORARY 2t NEW <br /> r, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I Type Construction Disposal Site_No. of Units !I -Equipment Storage/Cleaning Location(s) _ <br /> .6. ❑ PACKAGE TREATMENTI"PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name „fit q <br /> Plant Location r <br /> Plant Capacity .5 _..� No.Units Served - 4 <br /> 7. ❑ LAUNDRY For July 1,=June 30, 19 <br /> SIZE: C] Less Than 1,000 Sq. Ft., <br /> ❑ More Than 1,000 Sq. Ft. <br /> r ❑ DRY CLEANING,Chemicals Used/Amount/MO. — <br /> II <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,andr �es and regulations o he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �I.CC -- <br /> I Z 5�8 t7 <br /> �v J 5' eL--60 <br /> FOR DEPARTMENT USE ONLY <br /> ( <br /> anuary 31 July t d Fee Is Due: ❑ ANNUALLY' 13PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Ry J ❑ HeceiveRaEMuly�t <br /> T <br /> 1 13ILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> y BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 1t b- <br /> PRORATION _ - <br /> [• PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 47 dP7 6) issuance Uate Mai!ed Delivered <br /> Permit No. _ <br /> Receipt No. CKTON CA 95101 <br /> Recened by <br /> ``Date STO , <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SER1rICES 1601 E.HAZELTON AYE.,P.O.Box 2009 <br />