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a+. TO <br /> Applications Will Be Processed When Submitted ProperlyCompleted. e sure <br /> APPLICATIOU-T - <br /> I (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1 <br /> Application is ereby made to car on biness'n the'urisdi tional area of the 5a oaqui Local Health District <br /> AP <br /> w Business Name DBA) <br /> Address <br /> z Owner Address ; <br /> 4 M <br /> 9 Firm Partners, Addresses and Tel hone Numbers <br /> a Business Telephone No. 6 _r Emergency Telephone No. r <br /> f alip <br /> Contractor Licence Nv, p� 7 j <br /> Applicants Name (Print) r * tk Rr_� Title Date <br /> tea. , ti <br /> Please check Applicable-Category-(1-7) and Fill in the Required Information ? <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 Disposal Sites <br /> For July 1, <br /> r Description(Make/Yr.,Color) <br /> iIL -'I CAL. License No. CAL. License Renewal No. <br /> Serial:No.� - �r< y <br /> Capacity Ga1.,Weights & Measures No. <br /> yf <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For iJuly 1, June 30, 19 <br /> No.'. <br /> o. of Vehicles Stored 1 <br /> 111, <br /> NO.of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TEST 1� <br /> , -R.S. or R.C.E. No. <br /> ` R.S€or R.C.E. Name A* V� <br /> Test cation r Test Date/Time <br /> r 4. � SANITATION PERM15s <br /> Job'Address/Location <br /> Owner ae�' �- �r1.L'��P..sa }� Address 7 900 <br /> 1:1 SE11 � <br /> PTIC TANK 13 CESSPOOL IT LEACHING FIELD ❑�SEEPAGE PIT El PACKAGE PLANT <br /> 11 PERMANENT TEMPORARY ❑ NEW °� REPAIRS OTHER <br /> I k <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site 4 <br /> Noof Units Equipment Sto age/Cleaning Location(s) <br /> p 6. 0 PACKAGE TREATMENT PLANT For July i, -Ane 30, 19 � r <br /> Where Certified <br /> Operator Name 'Y ' <br /> Plant Location t ;. <br /> No. Units-Served <br /> Plant Capacity 0 <br /> 7. 11,❑ LAUNDRY For July 1, -June 30, 19 Ir { <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, <br /> ❑l'DRY CLEANING, Chemicals Used/Amount/Mo. ` <br /> it } <br /> ii 1 hereby certify that l have prepared this application and that.the work will be done in accordance with San Joaquin County <br /> € ordinances, state laws, and rules d regulations of the an Joaquin Local Health District. <br /> AP.PLICANT'S SIGNATURE X Y <br /> FOR'DEPARTMENT USE ONLY % <br /> Fee Is Due: ❑ ANNUALLY•, ❑ PER UNiT PER SITE El EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> tBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE ' EXPLANATION DATE DATE REMITTED AMOUNT <br /> f FEE <br /> LESS <br /> I PRORATION I <br /> is PLUS j <br /> 1 PENALTY <br /> OTHER <br /> I: OTHER <br /> Received by Date Receipt No.. Permit No <br /> Issuance Date Mailed - eli red <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 20t19"`�ST KTON, LE <br /> 85207 <br /> ` T'r�cP !�f cr.� TSI-E 7 <br />