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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sijtn The Application. <br /> APPLICATION ; <br /> r (For Non-Transferable, Revocable, and Suspendable) SEPTAGz dr+r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby rUdeto carryon b sin ss in the jurisdictional area of the an Joa�ujln Local Health District <br /> FBusiness Name (DBA) .0,A. ii i_sy- �° Address �• �JL f`•3i����'�0 j <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. —7!" Emergency Telephone No, <br /> Contractor Licence No. ate+ <br /> L Applicants Name (Print) iCl�� '_ 1�7�C Title. Date —7 <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) CNA <br /> For July 1, . June 30, 19 Disposal-Sites } <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License I No. •t <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> r� <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R or R.C.I 'No. <br /> Test Location TIMP FA Jft0% <br /> 4. Of-SANITATION PERMIT ` <br /> Job Address/Location <br /> Owner ee ddre-ss <br /> e® SEPTIC TANK i❑ CESSPOOL LEAC NG IELD 11 SEEPAGE PIT ❑ PACKAGE PLANT • <br /> PERMANENT • ❑ TEMPORARY NEW„ T❑ REPAIR' ❑ OTHER <br /> �.. • is ,) <br /> 4 . <br /> 5.` ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �E •t • , a <br /> Type Consfrtiction Disposal--Site <br /> No. of Units. !_5 m ;Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGETREATMENT PLANTf For Jul 1, -June 30, 19 <br /> Y <br /> Operator NameA Where Certified <br /> Plant Location P a '• _: <br /> 143 <br /> Plant Capacity n . No. Units Served H <br /> 7. ❑ LAUNDRY For--July 1, June 30,19 • y~, •�_^ a " ' '" <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., y❑ More.Than'1,000 Sq. Ft. t <br /> ❑ DRY CLEANING,Chemicals'Used/Amount/Mo.- <br /> Hom o0.wnelrorltcensettiagenY'sslgnittrnGRrf44i4rtt11'3fntloti�Irlg"1c41rfnGoQtthcwnrk for +hlhthlspertnlflSlis±±gelsl#yjty��E��l± <br /> in suckmanner as to become subject t0of f.aiifornla:' �, • - - <br /> Contractor's hirinR or sttb•contracting signoturl, cottifin, the followiriq: "I cfrt;fy thus In lily{1r;rformnnce of 111i Viol'k for Wt110INS pormil fa l Ali S�,f flit fl <br /> +-em�IQy persons subject to workman's eomponsatian jaws of California." 'J• <br /> .a It,hereb �certif that I have prepared this application and that the work will be done in accordance with SanAJoa Joaquin Count <br /> Y Y` P P PP q Y <br /> 4 ordinances, state laws, and r I ;end r gulations of the Sa oaq� •n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> <L't2ogm V10 <br /> Giv-0 , 01 <br /> ` T FOR DEPARTMENT USE ONLY <br /> I 3 r <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT t ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> .DATE DATE.., REMITTED. t ' " "" AMOUNT ? <br /> FEE s <br /> _ fl <br /> LESS <br /> PRORATION 6/ <br /> PLUS <br /> 4 PENALTY } <br /> OTHER _ <br /> � W2001.. <br /> OTHERReceived by Date Receipt No. Permit No. Issu nce D elAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON .,P.O.Bo <br /> r <br />