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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application.
<br /> APPLICATION y
<br /> -- jj (for Non-Transferable,Revocable,and Suspandabie) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE'
<br /> Application is her, y made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> Business Name (DBA) 4 1e , _._.._ Address.,.. - - '-
<br /> z Ownatr...._...__-.:_... _ __..___.._._.... _ Address
<br /> J Firm Partners,Addresses and Telephone Numbers_ r
<br /> a Business Telephone NO - W � :y .,:.sr:-, ; ErrtetgenoY Telephone No,
<br /> _...
<br /> CL
<br /> -Contractor Licence No.`•:: _:.:....,.....�..7 ✓ '�
<br /> Applicants Name (Print).---- r .:.•--=---trG.i _.. _ f. -Tit#a d? e.� r� ;.C3Htt! __.._.
<br /> Please check AppNcable Category(1-7)and FIN In the Required Inf'ornuffloo a .• l
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE)
<br /> For July 1, _ '....._._June 30,19- Disposal Sites
<br /> Description(MakeNr.,Colo'). .......... _.
<br /> Serial No. ........... CAL.License No. CAL Iiollmse Renewal No.
<br /> Capacity-._.__. ____ _... �L"Vdeignts$Measures No,__-._ -___._..............
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD,-
<br /> For July 1, June 30, 19
<br /> No.of Vehicles Storedl.
<br /> _
<br /> No.of Chemical Toilets Stored _........._._........
<br /> 3. ❑ PERCOLATIONrTEST
<br /> R.S.or R.C.E.Name R,S,or R.0 E,No. _.__•._ _�..!. ...
<br /> Test Location _ Test Date/Time
<br /> 4. ❑ SANITATION PERMIT -fir .+�►
<br /> JOb Address/l:ocation „_ p� C✓~� •7 r.4 ?�!�. Q.Lt�_/�'/A!t> ,� ,��i7iG IA/tit
<br /> __
<br /> Owner . .. ��* ��r,,y�r="'z, ......... Address-,_
<br /> "-..- _
<br /> 131
<br /> EPTIC TANK ❑ CESSPOOL LEACHIN{3 FIELD ❑ SEEPAGE IT ❑ PACKAGE PLANT r
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER > ,}
<br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> ype Construction _.....___Disposal Site _
<br /> No,of Units .._....---._..__. ..__.......__..._, Equipment Storage/Cleaning Location(s)
<br /> S. ❑ PACKAGE TREATMENT PLANT for July 1.-June 30, 19 C_
<br /> Operator Name &t
<br /> --- WMrY CAftiflod ...._.......
<br /> Plant Location
<br /> Plant Capacity __r__..,,__ ._.._W No.Units ` • _._......
<br /> + r rrr+ .
<br /> 7. 1:1 LAUNDRY For July 1,-June 30, 19 - _ r �w I
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING,Chemicals Used)AmounVMo, de
<br /> ! Hereby certify tiiai:lve pr8paretf+this application and that the work will be donen:aecortiaace with San Joaquin County
<br /> ordinances;`state laws,and roll and r ulatio s of the S n Joaquin Local Heaitfh :)iitrict
<br /> APPLICANTS SIGNATURE X _..._......_ �•✓z � �>{' _ .. .......... . _- __....... __.- ._..
<br /> • * 3
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Due:D ANNUALLYi [3.PER LHWr © PER SIT+E 1 ❑ EACH ❑ January 1 s,Re"We'd Ry Jarl'Ary X D July 1 a Rrcewae By July 31
<br /> ---i BILLING REMITTANCE AMOUNT OL1E CHECxf0
<br /> SASE EXPLANATION 7 UArE OATE RemiTTED
<br /> A1AE3iJNT
<br /> LOS
<br /> PPROOFtATION ' ► ; _
<br /> PLUS ;
<br /> PENALTY
<br /> • t
<br /> tjTHER i
<br /> . MM.h ..- +•'M•r► rM+.�-. WMWMWMYtMYw—V—
<br /> ♦� a�y/
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<br /> �. _ . ... r, ,... Y� �.,.✓111� ��
<br /> Por"lit NO, lastatice Hata Milled
<br /> r APptxcan'r-li*TJM ALL+corral tr* I<MtlfelfaUWWAL WEALTH PEI11NT8IiE MCES tifst E Iuz>rL Tor►Avt.,w.a snit zone sroCx7ow,cA ss�or
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