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Applications Will Be Processed When Submitted pLICATIONe eBe u <br /> (For Non-Transferable,Revocable, and Suspendable} SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' LIQUID WASTE <br /> Application is hereby ma c�to carry on business in the jurisdictional area of the San Joaquin L�l <br /> l� ✓r Health Dist <br /> "N It 7 Address. <br /> Business r��me (DBA) r <br /> Address <br /> a- Owner I <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephy e No. Lee— <br /> Business <br /> � <br /> CL <br /> Business Telephone No. �NTaGO7_� '4fv ��j Z 1-40 AiJD <br /> Contractor Licence No. T Title �`/a7A70 2 Date_ B <br /> L Applicants Nam <br /> e (Print) <br /> ,mss ��Q <br /> Please check Applicable Category (1-7)and Fill in the Required Information �I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> r <br /> Description(Make/Yr., Color) CAL. License Renewal No.----I , <br /> Serial No. CAL. License No. <br /> i Capacity Gal.,Weights & Measures No. <br /> i I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored f <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. F111SANITATION PERMITJa <br /> Job Address/Location L� `✓�° a <br /> Owner �'� �o YtI�' �`0 ir <br /> �� Address �7t� ❑ PAC AGE PLANT _ <br /> ❑ CESSPOOL l} ❑ LEACHING FIELD ❑ SEEPAGE PIT <br /> ❑ SEPTIC TA K ❑ REPAIR OTHER <br /> ❑ PERMANENT <br /> [1 TEMPORARY- 13 NEW ]� <br /> 5. ❑ CHEMICAL TOILETS For July 1,'-June 30, 1Disposal Site <br /> M Type Construction .1 <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> t-+ Plant Location No, Units Served <br /> k 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a hat the work will be done in accordance with San Joaquin County <br /> t I hereby certify that I have iprepare this appli _ <br /> ordinances, state laws, and r d regula i nsoft he Joaquin Local Health District. <br /> ` APPLICANT'S SIGNATURE X <br /> y. <br /> FOR DEPARTMENT USE ONLY <br /> January 31 July 1 & <br /> Fee IS Due' ❑ ANNUALLY ° ❑ PER'UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By - July July 31 <br /> EMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> iFF FEE <br /> 4 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> F � <br /> OTHER { <br /> OTHER <br /> Date <br /> Re—cell No. Permit Na. <br /> Issuance ate Mailed Delivered - <br /> Received by - 5601E HAYELTOI AVE.,P.O.Sox 20191;;rS TON,CA 95 <br /> APPLICANT=RETURN Al COPIES TO: - <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES- fir <br /> -_- -ate - ry�h _ - ♦. ,...Y�,y,.: �i/ y..-�_ � �` - - <br />