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Applications Will Be Processed When Submitted ProperlyCompleted tiesure io:71 n inu.+NNli�a.wl1 <br /> r IAPPLICATION <br /> } (For Non-Transferable,Revocable;and Suspendable) SEPTAGE b <br /> v ENVIRONMENTAL HEALTH PERMIT <br /> r LIQUID WASTE <br /> t` r k <br /> • Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) MnT)nna1.d.. P.t �' Rr 13a r-khnP, _Address�l�2 <br /> 5_ Hildreth L ne <br /> z Owner Address ,f <br /> a <br /> Firm Partners, Addresses and Telephone Numbers .957-4027 <br /> - <br /> aBusiness Telephone No. - Emergency Telephone No. <br /> Contractor Licence No. Y <br /> Applicants Name (Print) �' R icTlnna.l d —Title �Wrie ` ,+ Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information r ) <br /> 1. ❑ PUMPER VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE) 4 _ <br /> 'For Juky 1, - June30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19.I <br /> No. of Vehicles Stored Sc <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ! <br /> R.S. or R.C:E. Name R.S.or R.C.E. No. O <br /> Test Location, Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc do + 4 <br /> Owner Address <br /> k SEPTIC'TANK 13 CESSPOOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT.' , <br /> LJ 'PERMANENT- ❑-TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL-TOILETS Forlly 1,-June 30, 19_ t <br /> ;f. Diposal,Si ie� \ <br /> Type Construction s <br /> . - �'�;, - <br /> ` ! .- 'E ui <br /> No. of Units menf Storage%Cleaning Location(s) <br /> = i q p a <br /> rune 30-.19 <br /> 6. ❑ PACKAGE TREATMENT PLXNT—..For Ju <br /> v� .s =' Where Certified <br /> ! Operator Name: y <br /> i Plant Location <br /> y . No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -'June 30, 19 <br /> s SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑rDRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that,l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, n 'les and reg a ns of the 5 n Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLYH ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received <br /> R MlTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t- DATE D TE REMITTED AMOUNT <br /> FEE + tc <br /> LESS <br /> PRORATION <br /> PLUS v <br /> PENALTY <br /> r <br /> OTHER - <br /> OTHER j r <br /> fid- .$`IZA to v <br /> Received by Date 1 ,Receipt No. Permit No. ssuance ate Mailed Delivered <br /> - AALI CANT—RETURN ALL COPIES TO:—,ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AY£.,P ao 200 CKTONQ,CSA 85201// <br />