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dW <br /> ,etsp �g'''*"',,1�r <br /> 4 <br /> q 30 <br /> i �jkcq <br /> , <br /> Applications Will Be Processed When Submitted Propedy Completed.Be Sure To Sifln The Application, <br /> APPOCATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT {� <br /> = LIQUID WASTE <br /> Application is h eb made to carry on business in the jurisdictiona!area of the San Joaquin Local Health District ?� <br /> Business Nsme(DBA) <br /> �"z 2 U� Address�.��„_ ,•}' �'���%'T« - s::' � <br /> t' Ow,1er _ Address , <br /> A Fi Partners,Addresses and Telephone Numbers Mti <br /> s: E,sines Telephone No. �b rS'� Emergency Telephone No. r <br /> Contractor Licence No. .z <br /> zs,.L APPlicants Name{Print , <br /> Title —Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> } i. ,© PUMPERVEHICLEPERMIT REGISTRATION(FOR EACH•VEHICLE) <br /> For July 1,' June 30,19 Disposer Sites y' <br /> Description(Make/Yr.,Color) <br /> 5erfal No CAL.License No. _ CAL.License Renewal No. _-------- <br /> Capacity Gal.,Weights&Measures No. <br /> 'EqulpmerttParkingAddress ,s;g <br /> S � , <br /> -r2."❑ PUMPER YARD <br /> For Juiy 1, "" June 30.19 <br /> s <br /> ,,.,No.of Vehicles Stored 77 <br /> NO.of Chemical Toilets Stored _ <br /> `$1'` `❑ PERCOLATION TEST <br /> Name R.S.or A.C.E.No. <br /> 5;??Test Location Test Date/Time ` r <br /> dr SANITATION PERMIT <br /> ._ <br /> r .!o AdariaW ocetion" <br /> , sQwner�Y.:ac�`lxGa✓' - d Address 1.. <br /> SEPTIC"TANK 0 G_ESSPOfl:-", LEACHING FIELD 11 SEEPAGE PIT 13 PACKAGE PLANT 1 <br /> �r 'PERMANENT '[�MPORAP,Y NEW ❑ REPAIR ❑ OTHER <br /> s <br /> l5 ;i❑ CHEMI4AL,TO1LET3 i For July 1,-June 30,19 <br /> ty Type Cprtatr[rct(or► ' / 1 Disposal Site } <br /> NO.of Units ` Equipment"Storage/Cleaning Location(s) <br /> 6- PACKAGE TREATMENT-PLANT For July 1,-June 30,19 f <br /> _ s{ O torNarne"-�L� t Where Certified <br /> para - <br /> r Plant Lor aeon <br /> f <br /> is szir.�" No.Units Served Jf <br /> .� Pn!Cpacly <br /> �u 7 Q LANNpRY'For July 1; June 30,19 1 <br /> y '?SIZE ❑ Loss Than 1,000 Sq.Ft., -13 More Than 1,000 Sq.Ft. ' <br /> © DAY CLEANING `:hemicalc Used/Amount/Mp: <br /> 21 <br /> I hereby certify that I have prepared'this`app;ication and that the work will be doneInacroraance with San Joaquin County ` �Y <br /> ordinances,. laws.and rules and regu• I f the n Joaquin Local Health District is y <br /> r . s <br /> APPLICANTS SIGNATURE_ X <br /> 1 FOR DEPARTMENT USE ONLY : <br /> Fee Is DUe.❑ ANNUALLY ❑PER UNIT ❑PER siTE ❑ EACN - ❑"Janpary t A Recened.@y.tanuary 31 ❑July t 8 Recurvetl Ly July 31 <br /> - eAse^ EXPLANATION- 13ILLING - REMITTANCE $ AMOUNT DUE REMIT KED <br /> - - .- - DATE - DATE REMITTED �•�- AMOU14T --f•: <br /> FEE t ; <br /> LESS - <br /> PRORATION - •" <br /> PLUS - <br /> } : PENALTY - - - - <br /> OTHER - - <br /> .�.. ....OTHER .... ._ —� ..�._ _ ...._.__..�. - - -•--- �•- , <br /> i Received try Dale - .Receipt No. PerMil No, IS3u n[e Dale Mailed Deiivered <br /> ;, !$ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH P£RNIMSERviCES 1601 E.HAZELTON AYE..P_0.aoa 7009. STOCKTOK CA a5 <br />