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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign Ine Appei"litu,t..� <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) I SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT r j <br /> LIQUID WASTE? -r`•` : <br /> Application isghereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District 1 <br /> rBusiness Name (DBA)J1�L �d 'at-45 Address ?� <br /> Owner ! Address .n <br /> Firm Partners,Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> Business Telephone No. 1 <br /> Contractor Licence No. i Date <br /> L Applicants Name (Print) Title <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 - . Jr* - Disposal Sites <br /> r <br /> Description(Make/Yr.,Color) CAL.License Renewal No. <br /> CAL. I.ieenee-N0. <br /> Serial No. g +,k�„i_r:•... �. <br /> Capacity --` ..•,, a1�YUei hts 8 M_eMasNa-"”" <br /> Equipment Parking Address r <br /> 2. ❑ PUMPER YARD <br /> June 30, 19' + <br /> For July J, 011% ) <br /> No. of Vehicles Stored - <br /> �� No. of Chemical Toilets Stored ~ <br /> 3. 13PERCOLATION TEST R.S.or R.C.E:No. ' <br /> 3 ✓� <br /> j R.S.or R.C.E.Name ( <br /> Test4. Location <br /> Test Date/Time! �r <br /> L�J"SANITATION PERMIT � I•»-► .�- � <br /> } Job Address/Location <br /> Address s � ... <br /> Q.,PAGtKAGE PLANT 1 t <br /> 17 SEPTIC TANK ❑ CESSPOOL [ �Ew RING FIELD-=113 <br /> REP IR PIVD OTHER <br /> [IPERMANENT ❑ TEMPORARY F ❑ REPAIR <br /> t E t i <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19R <br /> Type Construction ' Disposal Site <br /> -Equipment Storage/Cleaning Location(s) <br /> No.of Units ,r C <br /> Ig• ❑ PACKAGE TREATMENT PLANT .For July 1, -June 30, 19 1%il —•�....�_.� <br /> � -•'Where Certified <br /> Operator Name (' <br /> Plant Location No-Units Sbrved E <br /> Plant Capacity E ` <br /> T. ❑ LAUNDRY >For July 1,-June 30, 19 i t ItA. <br /> f <br /> , ( 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., t❑ More Than 1 000 Sq. Ft. <br /> • <br /> 11 DRY CLEANING,Chemicals Used/Amount/Mo Y v `f -•* <br /> l j <br /> T ft . , <br /> 6 <br /> tfltii 1 i. ' <br /> I hereby certify that l av prepared this.applica ltlt on and that theo;rk �be done ih accordance with San Joaquin County } <br /> • ^= ) <br /> ordinances,state law an r•Sas and regUlatlohs of than a'- if,Local Health District. <br /> , <br /> APPLICANT'S SIGNATURE X .. - <br /> FOR DEPARTMENT USES-ONLY <br /> f <br /> �❑ PER,SITE _TEACH .❑January I &Received By January 31 ❑ July 1 8 Received By July 31 <br /> Fee Is Due: O ANNUALLY ❑ PER UNIT � REMIT t <br /> ' R BILLINGA REMITTANCE S AMOUNT DUE CHECKED r <br /> BASE EXPLANATION - PATE - 6A7E• REMITTED AMOUNT <br /> FEEAESS <br /> PRORATION f Z ` <br /> PLUS - <br /> PENALTY - <br /> OTHER ..._. <br /> •'i OTHER ... •.�- .. :;w - .F, .v .. .. >v,s r Tis:. <br /> + � j <br /> • ••' Issuanc .D e _ Mailed. - DalWered <br /> pate Receipt No. Pe it No. <br /> Received by - 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKYON,CA 96201 <br /> APPLICANT—RETURN ALL COPIES TO: EMVIRONMENTAL HEALTH PERMIT/SERVICES <br />