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r"': <br />•••••••• <br />... <br />APPLICATION <br />AppleCations-Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: <br />For Non-Transferable, Revocable, and Suspendable) <br />SEPTAGE ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />APPlication is her.r.by mad to car n u iniess in the jurisdictional area of th an 9kaquin o al alth D'stri <br />or" Business Name (DBA) k t.- ' L.-.L. - Address ' U C‘"4. <br />li Owner I___E_E—_..,, k.-1.1:\ _._T:171_LfsV._,,,_ Address *I C,50 0 L , ' L'Al ) <br />S.' Firm Partners, Addresses and TV, rujnbers <br />9(reAs6 441 _ _ t a. Business Telephone No. c (0 t--• I Emergency Telephone No. <br />i a Contractor Licence No. 35 I <br />;—T:-rS4. C,INIF-rs IV-71) V- <br />i <br />I 'r Applicants. Name.Mrint), 1--F- F \11/44.a_l_Mtkes.1—L___. Title C <br /> <br />Da <br />I Please-check Applicable Category (1-7) and Flit In the Required Information <br />0 PUMPER VEHICLE PERMIT REGISTRATION (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 ... <br /> • Weights'& Measiires-No, <br />Equipment Parking Address <br />0 PUMPER YARD <br />z <br />Fo'r jUly <br />No. of Vehicles Stored"' '- <br />No. of Chemical Toilets Stored <br />0 PERCOLATION TEST <br />R.S. or R.C.E. Name R.S. or R.C.E: No <br />Test Location <br /> Test Date/Time <br />4. r 0 SANITATION PERMIT . ,_,... - '1,-• % ' - ..i <br />. Job Addxss/Location .,.-I. Ti I- k,-• E.W - C._ i -... .. : , , „. _.. ' ..,''''' -,' .. <br />-Owner rt L V1/4.1 I I VA IN neN % Address _i_C-,1 1 A <br />1:1 .SEPTIC TANK 0 CESSPOOL EACHING FIELD 0 SEEPAGE PIT "ti PACKAGE PLANT; ' <br />13 PERMANENT 0 TEMPORARY NEW.7:-' s' f -4- --'.: AREPAIR i; 0 OTHER <br />i..f 0 CHEMICAL. TOILETS For July 1, - June 30, 19 <br />TYpe Construction Disposal Site , <br />N. of Units EquiPment Storage/Gleaning .Location(s) <br />6,5: 0 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name Where Certified <br />Plant Location <br />Plant Capacity No. Units Served <br />7. 0 LAUNDRY For July 1, - June 30, 19 <br />SIZE: 0 Lass Than 1,000 Sq. Ft., 0 itectre Than .1900 Sq. Ft. <br />0- DRY CLEANING, Chemicals Used/Amount/Mo. <br />2 , <br /> <br />" * <br />I hereby certif hat I have prepared this application and that the work will be done In accordance with San Joaquin County <br />ordinances, st e and rules d re ulation of the San Joaquin Local Health district. <br />APPLICANTS SIGNATURE X <br />Fee is Due: 13 ANNUALLY <br />FOR DEPARTMENT USE ONLY <br />0 PER UNIT 0 -PER SITE 0 EACH 0 January 1 & Received By January 31 0 July' & Received By July 31 <br />BASE EXPLANATION <br />.....__ <br />BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ • <br />REMITTE0 <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE. 4 Lt"-S 4.--1-6 <br />LESS <br />PRORATION 49. <br />.••-• . <br />PLUS <br />if <br />OTHER <br />PENALTY <br />- <br />..../ <br />OTHER ,.... <br />41 1.'S 1 1 Ci_ .3 03 (dp 65 Li ,._s • <br />Received by <br />2120•11,AWIT <br />Dale Receipt No. <br />ISCTI lama a,. a•NISMIC. -r."... ek.11/MoNS2112C1211.21 12021 <br /> <br />' Permit No. Issuance Date Mailed <br /> <br />1.12 .C.121.11,..E.Sillne. 411ral .6 U11.1CiTn2,2 61/F D2.2 slay *rim <br />Delivered <br />frrrtnirrau <br />. <br />r.22 oaarta <br />•