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Applications Will 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 tcarry on business in the jurisdictional area of th San Joaquin Local Health District <br /> �- a•���'��� ���} <br /> Busindss Name(DBA) Address � <br /> c Owner Address <br /> 10c <br /> Firm Partners,Addresses and Telephone Numbers <br /> IL Business Telephone No. r' - 9-4,0 Emergency Telephone No. <br /> Contractor Licence No. — 3 Title rtAAAXCJFK Date —I <br /> t-q Lis� <br /> Applicants Name (Print) 1� SING, <br /> � � <br /> Please cc 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 /> N c7rption(INake/Yr.,Color) CAL.License Renewal No. <br /> Serial No. CAL.License No. <br /> Capacity - Gal.,Weights 6 Measures No. - <br /> Equ$meht Parking Address <br /> 2. 11 PUMPER YARD <br /> For July1, June 30, 19 <br /> No.of Velicles Stored w <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.-;r R.C.E.No. <br /> R.S.or R.C.E.Name <br /> A.S. <br /> lion <br /> T4s6P <br /> �C.E. Test Date/Time <br /> _ q, IPSANITATION PERMIT <br /> Job Address/Locationr� <br /> �ddress d 7-3 <br /> - <br /> OwnerdRa?a ❑ PACKAGE PLANT -� <br /> 11 SEPTIC TANK 13 CESSPOOL O'CEACHING FIELD B SEEPAGE PIT ❑ OTHER <br /> g 'rERMANENT ❑ TEMPORARY <br /> 13 NEW L�`FiEPAIR � <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 E <br /> Disposal Site l t <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No.of U�its — <br /> a - 4 <br /> 6. ElPACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified f <br /> '= t <br /> Operator Name - <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7.'111 LAUNDRY For July 1,-June 30, 19 - <br /> ❑ Less Than 1,000 Sq. Ft., ❑IMore Than 1,000 Sq. Ft. ' <br /> SIZE: <br /> ❑•ORY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I h e prepared this applicati d that a ork will be done.in accordance with San Joaquin County. - <br /> ordinances,state laws, d ules and r ulations of a an Joa n Local Heatth District. <br /> APPLICANT'S SIGNATURE A zi� <br /> I FOR DEPARTMENT USE 1. ONLY ,, y - <br /> = <br /> PER UNIT PER SITE ❑ EACH ❑ January t 8 Received By.'an ry 1 ❑ July t 8 R eivRE(Tiny 31 <br /> Fee Is Due:❑ ANNUALLY <br /> BILLING REMITTANCE a•,. . AMOUNT DUE CHECkEO <br /> BASE x EXPLANATION DATE DATE ;- REMITTED -' AMOUNT 4 <br /> FEE <br /> LESS 6 <br /> PRORATION •+'•' r� <br /> PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> Receipt No Permit No. Nsuance DateMailed eliver <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Bo:2009 ST--- ON,CA 201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br />