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6 <br /> is <br /> Applications WIII Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> yy� APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE ! <br /> I'll ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE <br />+i Application i erebv made to carry on business in the jurisdictional area of the San Joaquin Local Health Dish <br /> pBusiness Name(DBA) j _ 1I f�L— '� Address—Jit'-- -r7�--cam <br />' <br /> Owner— ��, Address <br /> ��z:ca —T_- <br /> Firm Partners,Addresses and Telephone Numbers --- 1 <br /> gBusiness Telephone No._3G't_ r! Emergency Telephone No. ? r, <br /> Contractor Licence No. F <br /> L <br /> Applicants Name(Print) ZG e Tale 1 03te y�� <br /> I Pease check Applicabla Category('-7)and FIII in the Requlr d Information <br /> 1. D,PUMPER VEHICLE_Eim r REGIdTRAT1ON(FOR EACH VEHICLE) <br /> For July 1, June 30,19 Disposal Sites <br /> •Description(Make/Yr..Color) --- <br /> Serial No. CAL.License No. CAL.License Renewal No.— <br /> Capacity _ Gal.,Weights&Measures No. <br /> Equipment Parking Address_- -- — <br /> r.. 2 ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored t <br /> No.of Chemical Toilets Stored'. <br /> 3. ❑ PERCOLATION TEST 7 <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. — <br /> Test cation — Test Date/Time — ---N <br /> a <br /> 4. ffJ SANITATION PERMIT <br /> Job Address/L ion Z O:7- I <br /> Owner: 1Z�L•[�� /P Addruss _ —Y / G �s R <br /> CY�SEPTIC TANK L7 CESSPOOL �--y,�LEACHING FIELD SEEPAGE PIT L� PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY I-7 NEW ❑ REPAIR ❑ OTHER <br /> Tr <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Site <br /> 3 <br /> Type Construction Disposal_ p � ;c <br /> No.of Un;t; Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 ` <br /> i Operator Name Where Certified <br /> Plant Location c' <br />=1 Plant Capacity No.Units Served w' ; <br /> a <br /> 7. ❑ LAUNDRY For July 1,-June 30.19 <br />'`. SIZE: ❑ Less Than 1,000 Sq.Ft.; ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING,Chemicals L;-ad/Amount/Mo. _ <br /> • n <br /> 5 <br /> I hereby certify that I have prepared this application and that the work vvi!I be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and ulations of th Joaquin Local Health Uigtrict. <br /> 01 <br /> APPLICANT'S SIGNATURE X <br /> e <br /> 1 <br /> FOR DEPARTMENT U NLY <br /> ed By <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT L7 PER SITE ❑ EACH ❑ nuary 1 d Received By January J1 El 1 d ReC01V REMITuIy 31 <br /> BASE EXPLANATION BILLING MANCE $ AMOUNT DUE CHECKED <br /> DATE UUUVVV ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION . <br /> S'. <br /> PLUS <br /> PENALTY <br /> OTHER — <br /> OTHER `• <br /> Received Dy Oals R.)eerpl N. PerMll No. I uan.,e Dale Marled <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMEATAL HEALTH PERMIT/SERVICES loot .HAZELTON AVE. P.O.aor<2009 STO TON,CA 95201 <br /> a . <br />