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.y; t Applications Will'Be Processed When Submitted Properly CompleteBeSure +� ;io <br /> " APPLICATION <br /> (For Nan-Transferable,-Revocable,yind 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 Jo quin Local Health District <br /> a Business Name (DBA)D AA ,, lJs�'�iJC' Address-PC) _ <br /> aOwner Address " <br /> 1 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No..:, <br /> aBusiness Telephone No. ' <br /> Contractor Licence No. . �.-�. � l M TitleC�--}� �M�TQ Date <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information y <br /> 1.. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) rr <br /> For July V Junb"30,-19 - - = Disposal Sites - <br /> Description(Make/Yr., Color) CALLicense <br /> ,„.•--• r . Renewal No. <br /> Serial No. CAL. License No. � <br /> Sr_. <br /> Capacity Gal.,Weights'&'Measure54No. ° �` <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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. ` 1 <br /> R.S. or_R.C.E. Name <br /> Test�Lo�cation ~Test Date/Time R <br /> 4, t� SANITATION PERMIT ' <br /> Job Address/Location ) ' <br /> Owner Address <br /> ❑ CESSPOOL LEACHING FIELD C�SEEPAGE PIT ❑ PACKAGE PLANT I <br /> ❑ SEPTIC TANK ❑ OTHER <br /> [I��ERMANENT ❑ TEMPORARY. ❑ NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July l'- <br /> r .-.* -�- .� ~. _. pisposaI:Site s ....;f wy <br /> Type Construction •°�•, <br /> ` �+! Equipment Storage/Cleaning'Loccation(s) ` „` <br /> No. of Units y <br /> 6. ❑ PACKAGE+REATMENT PLANT For July 1, -June 30, i9 ,. Where Certified„i9 <br /> Operator Name f <br /> 'Plant Location <br /> Plant Capacity t� F No. Units Served x <br /> '1, -June 3D, 19 <br /> 7. 11 LAUNDRY IL, ' uly�_ <br /> SIZE:) ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING', Used/Amount/Mo. <br /> r ,��� � ! 4W:�:M.i {..1 ��. � 1 �`E 51...- .,► ,�+�s;,� a s! � <br /> I hereby ertify that I hav prepared thi. applicaEio nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r lations ' San a in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> { <br /> -FOR DEPARTMENT USE ONLY t <br /> '”Fee IS Dile: ❑ ANNUALLY PER UNIT PER SITE El EACH ❑ January 1 &Received By January 31 •;❑ July 1 E.ReceivedREMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t BASE TEXPLANATION r "PATE, DATE- ... _)REMITTED AMOUNT <br /> a o J <br /> FEELESS <br /> 3 J <br /> PRORATION <br /> PLUS t #` ?t•yr a .�....,.�+ - <br /> PENALTY - - <br /> OTHER ..1,„,✓: „s. � '� -. <br /> OTHER -. • <br /> Permit No- issuance Date Mailed Dekivered <br /> Received by Date Receipt No. - <br /> ' 'APPLICANT'RET UAN ALL COPIES TO:1 ENVIRONMENTAL'HEALTH PERMITlSEFiV10E5- -- 1601 E.HAZELTON AVE.,c i60V )fig� S 000'94 ��g �� <br />