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Applications Will Be Processe, 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 /> 1 <br /> Application is her y made tq�rry on business in the jurisdictional area of the San Joaquin Local Health District n <br /> Pr Business me (DBA)�'11�° e[w+L,�+� Address p0 9v -� 4 <br /> Owner�1 G(G SSE CA_ Address ZLG N ,/1/a irl.,!'e ✓ - ` ' <br /> Firm Partners, Adtlresses and Telephone Numbers?K1C SfE£�F 7a/S' 86 OF <br /> K Business Telephone No. .3�of 3 y33 Emergency Telephone No. �'K'u' <br /> Contractor Licence No. .A9 S 721 <br /> L Applicants Name (Print) 112IC14 SAVE Title 6&)r-- Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ 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. <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 _ <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test-Date/Time <br /> 4. GYSANITATION PERMIT / n e /fes nf. <br /> Job Addr /Locatio ;L-L/(100 -au'a. <br /> Owner .a 15 Address 1�—.2(//9-0 * � <br /> E <br /> ErSEPTIC TANK ❑ CESSPOOL IV LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> Iil-PERMANENT ❑ TEMPORARY IYNEW ❑ 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity 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. F}. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre ared this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and reg ti s the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT DW(P SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �l <br /> Received by Date Receipt No. Permit No. Issu nee Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVIT5- n1601 E.HAZEL TON VE..,P.O.aoa OCK N,/ <br />