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Applications Will Be Processed When Submitted Properlycompletiell or aura rv—ill +-� <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati�;s hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health DistricCt` n- <br /> on <br /> Address-171- ��r � - <br /> Ch Business Name (DBA) <br /> Address <br /> a Owner <br /> Firm Partners, Addresses and T lephone Numbers Emergency Telephone No. Oto <br /> CL Business Telephone No. Z <br /> a <br /> Contractor Licence No. Date <br /> J Title ' <br /> Applicants Name (Print) rt r e; cr'll '"R SERVICE <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> LL.,3;•_ial��.1 .Sr_i I iLj t '11i <br /> iF� So. �Jra � Sit��h*an, Calif. 952051 ,4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l.h 3;� 3 'if" CStoc tIQ 'S Llif ' 5205 <br /> For July 1, June 30, 19 Disposal Sites { <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity GaL, Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addres cation r <br /> Owner <br /> Address <br /> � <br /> 11 SEPTIC TANK C3CESSPOOL LEACHING FIELD Yu SEEPAGE PIT CI PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) �n <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified v <br /> a <br /> Operator Name Qa <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of th.q,.San Joaquin Local Health District. 0: �WFR SIM <br /> �l <br /> �' <br /> APPLICANT'S SIGNATURE X Z..J. :.° . G �s '``==" iii • J <br /> F �. . <br /> -7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEED <br /> LESS <br /> PRORATION c i <br /> PLUS <br /> PENALTY <br /> OTHER � <br /> OTHER <br /> ' 4 ssuance ate Mailed Delivered <br /> Received by <br /> Dat Receipt No. Pe mit No <br /> APPLICANT—RETURN ALL COPIES 7D: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2099 $TOCKT <br />