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Applicafilms Will Be Processed When SubnIttled! Properly Completed. So Sur* To Sign The Applicattioo, <br />APPLICATION <br />Air` (For Non-TransWable, Revocable, and SuspendaMoll SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />L*W8 WASTE <br />Applicatiop,js hewby m0djjuarryqs,,Pus)pe* in the jurisdictional area of the SaWqaqu <br />,jp,L9S9I Healihistrict <br />--sinass� a (DBA) Addr0 <br />V <br />7-v 'd <br />Owner Address _a6Ak1.1_ 11;m <br />Firm Partners, Addresses and Telephone Numbers A J// <br />Business Telephone No. t.;A Emir4ency.Telophone No.%L1,t^_A . ... . ....... <br />Contractor Licence Na. <br />Applicants Name (Print) <br />Title &W " Date — <br />Ple"t check ApPlicable Category (1-7) and FIN In the Required Information <br />1. E3.,PUMPER VEMICLE PEnum REcailsTRA-rio.N qowsAcm VEHICLE) <br />For July 1. _—June 36. 19 Disposal _Sues <br />Description (Make/Yr., — — - __ _- - --- <br />Serial No_.. CAL. License No. CAL Lico"s Rienowall <br />Capacity .......... . ..... .. Gal.. Weights & Measures No. <br />Equipment Parking Address <br />2.0'PUIAPER YARD <br />For July 1__ ­ June 30. 19 <br />No, of Vehicles Stored <br />No, of Chemical Toilets Stored <br />3. 13 PERCOLATIOTEST - , ... _- <br />I <br />R'S' Of R.C.E. Name FWA, or-&C.E.- 40� <br />FOR DFPARTMMT USE ONLY <br />Test Ld6ationTest PAWTIP"a <br />E3 PER UNIT 13 PM Ircre 13 'EA04 January I <br />4. WSANITATION PEANT <br />- E3,jwy 1 -tuty 11 <br />-P YZ <br />Job Addr 4) 48e <br />Owner Address <br />�Ai1SE <br />,E] SEPTId"TANY, 0 CESSPOOL WLEACHING FIELD EksEEPAaE PIT C3 PAG 0E PLANT <br />AMOUNT DUE <br />, <br />13 PERMANENT 0 TEMPORARY '0 NEW Ulf �MA:10 13 OTHER <br />DATE <br />5. 0 CHEMICAL TOILETS For July 1, - June 30, 19 <br />is Construction Disposal Site <br />of Units Equipment Storage/0"ning Location(*) <br />6. 0 PACKAGE TREATMENT PLANT for July 1, - June 30, 19 <br />r <br />Operator Mame Where Cortified . ............... ... <br />Plant Location <br />LESS <br />tA5ttTION <br />Plant Capacity _._..._.w._..-.- No, Units Served <br />7. 13 LAUNDRY For July 1, - June 30, 19 . ..... <br />SIZE: Less Than 1,000 Sq. Ft.. 0 More Than 1,000 Sq. Ft <br />-0 <br />0 DRY 6LEANING, Chemicals U*sd1AAxwmt/Mo. . .......... <br />PLUS <br />PENALTY <br />jinereby certify that I have prepared this gipplication and that'the work will be done in accordance with San Joaquin County <br />ordinances, state laws aadl les.and r the San Joaquin Local Health District, <br />% <br />APPLICANT'S SIGNATURE )e' <br />— 0%rWL14,AN I —ft9t. � � �VrW* I W. �� T <br />'oaf L <br />. ........ . <br />4. <br />FOR DFPARTMMT USE ONLY <br />re* is ow: 0ANNuALLy <br />E3 PER UNIT 13 PM Ircre 13 'EA04 January I <br />AGetiow By Jaruasy 31 <br />- E3,jwy 1 -tuty 11 <br />�Ai1SE <br />9XPLAkXTION, BILLING AEMITIANCE <br />AMOUNT DUE <br />DATE <br />F"ITTED <br />FIR <br />LESS <br />tA5ttTION <br />PLUS <br />PENALTY <br />. ...... <br />OTHE A <br />__ ........ . . . <br />OTMER <br />— ------ <br />by ---- We <br />I""" Ift <br />_­�_ — 6� g_ als, —~�WVAU CA SMI <br />— 0%rWL14,AN I —ft9t. � � �VrW* I W. �� T <br />'oaf L <br />. ........ . <br />4. <br />