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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppliCarlon. a <br /> APPLICATION <br /> 10 <br /> (For Non-Transferable, Revocable,and Suspendable) f� // e SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE . <br /> Application-is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District y <br /> r • Address i <br /> r Business Name DBA) <br /> m Address <br /> a Owner <br /> J Firm Partners, Addresses and Teie one Numb�etr�s� Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Date <br /> a S Title .,m <br /> L Applicants Name {Print) rl <br /> • ti yc,—`iu�` } <br /> Please check Applicable Category (1-7) and Fill in the Required Information �-7%V t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> "r, rc �" <br /> `' <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. 2 <br /> Serial No. CAL. License 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 I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.G.E. No. 1 <br /> R.S. or R.C.E. Name - <br /> I �� 'Test Date/Time <br /> Test Location <br /> E C> <br /> 4. TVSANITATION PERMIT ` <br /> .00 <br /> Job Address/Location 1,111 1 67 / <br /> owner <br /> o A dress <br /> I SEPTIC TANK El CESSPOOL Oi LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> `PERMANENT <br /> ❑ TEMPORARY XNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1,.-June 30, 19 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. <br /> P <br /> ( ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F 1�r <br /> lication and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that l have prepared this app <br /> ordinances, state laws, a _ rul and regulations of th San Joa Lin Local Health District. <br /> T +- ,..QtA"3%1GE,S S=FTiC & SEt?.JER SERVICE <br /> APPLICANT'S SIGNATURE X � S . ©;� ?� ,Sinz.j;(0 , Calif. 95205 <br /> I Ph <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT WPER SITE ❑ EACH ❑ January 1 &1ReceW By January 31 I] July i &ReceivedBy-July31 <br /> ! BILLING REMITTANCE AMOUNT DUE CHECKED <br /> - .. BASE EXPLANATION DATE DATE EMITTED AMOUNT - <br /> { FEE <br /> LESS 4 <br /> PRORATION <br /> PLUS <br /> I PENALTY j <br /> OTHER { <br /> ' OTHER .. <br /> No. ermit NoIssuance P , Date .Mailed Delivered <br /> Date <br /> Received by� Receipt � 1601 E.HAZELTON AVE.,YEP.O.Sox 2009 STOCKY N,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:! <br /> ENVIRONMENTAL WEALTH PERMIT/SERVICES ' <br />