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Applications Will Be;Processed When Submitted Properly Completed. Be Sure TO SignTheApplication. <br /> APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) SEPTAGE <br /> " ENVIRONMENTAL HEALTH PERMIT „ <br /> LIQUID WASTE F <br /> Application Is reby ma to car on business in the jurisdictional area of the San.Joaquin Local ealth District s <br /> F Business Name { A)— `� Address—�� -: <br /> z Qwner ' Address ` tel <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL a Business Telephone No. Emergency Telephone No. <br /> I a <br /> J Contractor Licence No. r1 <br /> L Applicants Name (Print)_ �/ of-2 p ��� Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Intormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ; <br /> For July 1, June 30, 19 Disposal Sites ! <br /> I <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Lice^se Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> F i . <br /> Equipment Parking Address <br /> 2. ❑'PUMPER YARD <br /> For July 1, June 30, 19 r <br /> No. o0ehicles Stored X <br /> t No. of Chemical Toilets Stored i _ <br /> ! z d• <br /> 3. ❑PERCOLATION TEST <br /> �R.C.E. Name R.S. or R.C.E. No. <br /> R.S. o <br />!i I Test Date/Time <br /> r" Test Location III%t 40 <br /> 4. ❑USANITATION PERMIT 0 <br /> 6C. <br /> Job Address/Location -rt..—9� <br /> � Address � _...,,�..-.� <br /> Owne - .�. <br /> r w i <br /> �PTIC TANK CESSPOOL E2' FIELD ❑ SEEPAGE-PIT ❑ PACKAGE PLAN <br /> ❑_OTHER W <br /> B PERMANENT ❑ TEMPORARY I� NEW 'a.�' "❑ REPAIR 1 <br /> 5. ❑i CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of.Units Equipment Storage/Cleaning Location(s) { i <br /> 6. 1:1,PACKAGE TREATMENT PLANT For July 1,-June 30, 19 a <br /> P V Where.Certified.. t <br /> Operator Name <br /> Plant Location <br /> ' Plant Capacity No. Units Serveds <br /> E {1 <br /> 7. ❑ LAUNDRY For-J -June 30, 19 I <br /> SIZE:; 11 ;Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> t' ; <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. p i. <br /> i <br /> � 1 VV t �. <br /> I hereby certify that Ijhave prepared this application-and that the work will be done in accordance with San Joaquin County <br /> *r , ordinances, state laws;.and rules and regu ions of the San Joaquin Local-Health-District._.,_,.:r. <br /> jii APPLICANT'S SIGNATURE X All <br /> FOR DEPARTMENT USE ONLY ) <br /> F _ <br /> Fee Is Due: ❑ ANNUALLY; ❑ PER UNIT PER SITE ❑ EACH 13 January 1 &Received By January 31' ❑ July 1 &Received By July 31 <br /> 9 i _ REMIT £. <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> i . BASE ` EXPLANATION DATE DATE REMITTED - AMOUNT <br /> 1 _ <br /> w i <br /> ,+ir FEE <br /> v LESS <br /> .,.PRORATTfON"__""-.'.".-" <br /> PLUS <br /> PENALTY <br /> g - - <br /> _-'OTHER <br /> •. -...- .,,.,+res-^: -e--. �— . - _ �.�. --�r-�,..., ..+. <br /> OTHER <br /> e - <br /> _ Received 6y - Date - Receipt No Permit No. Issuance Date Mailed peSiv <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMIT/SERVICES... - .5601 E.HAZELTON AVE:,P.O.Box 2009 STOCKY N,CA 952 1 _ <br />