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."" Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,-'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1 <br /> Application is hereby made to carry on business in-the <br /> �jurisdictional area of the San Joaquin Local Health District.i-- <br /> m Business Name (DBA) -A' - � � Address Aq <br /> z Owner ,. ... Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. p Emergency Telephone,No. <br /> Contractor Licence No. Z Y" 4� <br /> z: - I . <br /> Applicants Name (Print) a - S1 S� Title �i Date <br /> Please check Applicable Category(1-7) and,F111 in the Required Information I <br /> 1. 11PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ca <br /> For July 1, June 30, 19 - _- =Disposal Sites <br /> 4 Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 4f <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No- of Chemical Toilets Stored <br /> 3. ❑ PERCOLATIONµTEST �. <br /> R.S. or R.C.E.'Name J R.&,d.r R.C.E. No. <br /> Test Lo tion <br /> ' Test Date/Time <br /> 4. SANITATION.PERMtT v <br /> Job AddresslLocation'EA ^ a4 �'A !TjTK <br /> � -�� U• <br /> a` <br /> Owner Address <br /> Z/ACHING FIELD �EEpAGE <br /> PIT <br /> ❑❑ PACKAGE PLANT' <br /> SEPTIC TAOTWER ;A <br /> Ell ERMANENT 13 TEMPORARY NEW REPAIR <br /> 5. 11 CHEMICAL TOILETS For July 1 June 30, 19 '� " <br /> r <br /> Type Construction --( - Disposal Site <br /> I -No. of Units i Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 � <br /> Operator Name .3 Where Certified <br /> Plant Location - <br /> No' nits Served <br /> 1 Plant Capacity s-*•� _ <br /> f 7. ❑ LAUNDRY For July 1,'=June 30;.;19 <br /> t SIZE: ❑ Less Than 1,000 Sq.`Ft., ❑ More Than 1,000 Sq. Ft. <br /> 1 ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r ' <br /> (j] <br /> I hereby certify that l have prepared this apply anon and that the work will be cion in accordance with San-Joaquin Coun'y <br /> ordinances,_state la nd,rules and^regulation of the,Sa JoaquinLocal Health Dis�ricf`�-i t <br /> APPLICANT'S SIGNATURE X <br /> ' t FOR DEPARTMENT,USE ONLY r <br /> _ Fee Is Due- ❑ ANNUALLY ., _❑ PER UNIT- __ ❑ PER SITE _� ❑ EACH ❑ January 1 -g ved ByyJanuary 31 ❑ July 1 &Received By July 37 <br /> REMIT <br /> 13ASE EXPLANATION BILLING REMITTAN EI $ AMOUNTDUE CHECKED <br /> DATE - DATE + EMIT7 - - - —AMOONT <br /> FEE <br /> LESS <br /> PRORATION <br /> I - PLUS <br /> PENALTY <br /> OTHER ,..,,.✓ .. .. ...r....-� .- •a°' .°y� _�. ,......- ---� - - - - <br /> t L i <br /> � 4 <br /> OTHER - <br /> a 9 - v <br /> Received 6y Date Receipt N. Permit No.•� ! - r ,. Issuange 1ja z ' Mailed Delivered, <br /> t <br /> APPLICANT—RETURN ALL COPIES•TO::,.�ENYIRONMENTALHEALTH PERMIT/SERVICES g 16p1 E.HAZELTON AY .,P.O.Baa 2009 .. STOGKAON,C 95281 <br /> I OU <br /> } <br />