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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication <br /> 3y <br /> APPLICATION lc-� <br /> (For Non-Transferable,Revocable, and Suspendable) SEpTAGE t <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> LIQUID WASTE Q <br /> Application is here made to carry on business in the jurisdictional area of th San oaquin Local Health District , <br /> y Business Name (DBA) ] Q, _Joaquin <br /> �`J� <br /> ��Q I S f+%V -gpmiz Address <br /> z Owner Address . <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone Na. �6- 60 Emergency Telephone Na <br /> -i r - If <br /> Contractor Licence No. rv3 d <br /> di <br /> Applicants Name (Print) ' <br /> Title Jr c� Date <br /> Please check Applicable Category(1-7) and F1II in the Required Information ; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 Disposal Sites <br /> I <br /> Description(Make/—X.,,,COIOr) _ _ .____.-. .— _.... -;--r - - <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &`Me'asurds No. <br /> E Equipment Parking Address <br /> 2. ❑ PUMPER YARD ._ _ <br /> E <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ., <br /> 3. ❑ PERCOLATION TEST-`. <br /> R.S.or R.C.E. No <br /> Name <br /> R.S. or R.C.E. N <br /> Test Date/Time <br /> Test L cation <br /> 4. SANITATION PERMIT, jj II _. C/` <br /># Job Address/Location S <br /> Owner Nc1v 57_�K7"b/t/ <br /> —k i ii !V 0—V GzyN ll E m Address <br /> UJ <br /> f ❑ SEPTIC TANK <br /> 11 CESSPOOL LEACHING FIELD 13PACKAGE PLANT SEEPAGE PIT Cy/1 <br /> ❑ PERMANENT 11 TEMPORARY ElNEW REPAIR ❑ OTHER �r. Q l <br /> G 5. ❑ CHEMICAL TOILETS;.For July 1, -June 30, 19 Q <br /> Type Construction <br /> Disposal Site, _ <br /> No. of Units `Equipment Storage/Cleaning Locations) <br /> 6. 13 PACKAGE TREATMENT PLANT"'For July 1, -June 30, 19'? } <br /> ' <br /> ---Where Certified <br /> Operator Name <br /> Plant Location _ �� � h <br /> # No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY for July 1, -June 30, 19 <br /> SIZE: ❑ Less Than_1,000 Sq. Fta, 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. F s` <br /> 4 <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County <br /> r ordinances, state laws, a rules an ..regu ons o.-t a San Joaquin Local Health_Distdct. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 4b.PER SITE ❑ EACH ❑ January 1 R Received By January 31 July 1 &Received By July 3� <br /> � � REMIT <br /> -- BILLING - REMITTANCE $ LINT DUE CHECKED <br /> _BASE —EXPLANAT.ION <br /> 'DATE" `" DATE'"'` --REMITTED", <br /> AMOUNT <br /> F FEE <br /> l LESS <br /> PRORATION <br /> PLUS _ <br /> i PENALTY -- <br /> OTHER <br /> k OTHER <br /> Date Receipt No- Permit No. issuance Date Mailed eSiver <br /> t". Received by _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAXELTON AVE.,P.O.aoK 2409 STOCK ON,CA 201 <br />