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Applications WIII 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 <br /> Application is hereby made to carry on business in the Jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (OBA) PARRM14 F �� =�R}�- AddressP40-EWX 1450 ST111<0,q'97- I <br /> Owner - Address.__ <br /> Firm Partners,.Addresses and Telephone Numbers _. <br /> a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. � .'�7- 3 <br /> Applicants Name (Print) =12*4CI=Y IS IM:S . Title;t�fti!A TQ— Date I Z•7-S _ <br /> Please check Applicable Category(1-7)and Fill In the Required Information „ ^� <br /> 1. CI PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19-__ Disposal Sites _- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No.'_._ 7 t <br /> Capacity Gal., Weights &Measures No. _ --- <br /> Equipment Parking Address -____ _ fe r I - - <br /> 2. El PUMPER YARD <br /> For July 1, Ju6e 30, 19 _. »�•F �� <br /> No. of Vehicles Stored? <br /> No. of Chemical Toilets Stored _ - ------ <br /> w - <br /> 3. CI PERCOLATION,TEST <br /> R.S. or R.C.E. Name t R.S.or R.C.E. No. <br /> Test Location ; Test Date/Time <br /> 4. rikIANITATION PERMIT <br /> Job Address/Location 230003 F"Je.0o6 Rc4. 7-L—i <br /> Owner 1 F?A1►..JtJ' S�O�2 � L p#jlp ddress <br /> S=PTIC TANK 11,CESSPOOL' 94"CEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Gl'rl=RMANENT i&TEMPORARY Oa-<EW 0 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 p <br /> Type Construction ._- _- Disposal Site 0 <br /> - -No.of Units _ Equipment Storage/Cleaning Location(s) --- <br /> 6. CI PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ! " <br /> Operator Name h -- Where Certified <br /> - - -- - <br /> Plant Location <br /> Plant Capacity 1 No. Units Served }� <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. _ <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. _._____—_—__-- + <br /> i <br /> I hereby certify that I ha prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and gulati of the Joa uin Local Health District. <br /> F!Sf � <br /> APPLICANT'S SIGNATURE - ------- - <br /> kFOR DEPARTMENT:USE ONLY <br /> , ,y o,. • I F <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI-� /-� PER SITE• 0 EACH '❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> l,. 1 ,-- r _REMIT <br /> BASE F%PLAN TION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> +t/ DATE t DATE REMITTED AMOUNT <br /> FEEPLUS <br /> LESS <br /> PRORATION Sol,CA�� <br /> PENALTY L.�i t Jt.%r•' 1 �►� :�f'»e_r� `,a•�C".t /r _.�i ti: - r. '-'v 1—_ __.-- _ <br /> OTHER <br /> OTHER <br /> by Date Receipt No. " Permit(do `q/ ' ", I!Mua Date' S ailed` liver <br /> APPLICANT—RETURN ALL COPIES TO,'�ENVIRONMENTAL HEALTA PERMIT/SERVICE$--:� 1601 E.HAZELTON AVE:,•P.O-Box 2009 9TOCKT N•CA 9/I--- <br /> Received <br /> J <br />