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Applications Will Be Processed When SubbmiitPLIproperly <br /> CATI OWple Be Sure To Sign The Application. - <br /> 0 (For Non-Transferable,Revocable,and Suspendebte) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> • LIQUID WASTE -w-`•"' <br /> Application is hereby made to car on business in the jurisdictional area of tile n Joaquin Local Health TDistrlgt <br /> �� —' Address JLSJ <br /> Business Name (DBA) Yi r <br /> Address <br /> c Owner <br /> 6 <br /> Firm Partners,Addresses andTelephone�N��Numbers _ Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. ¢ 'TI JG/,ATOK`" Date g��o"�o rP <br /> Title — <br /> �Applicants Name (Print) ""' •"' <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) CAL.License No. CAL. Lic::lse Renewal No. <br /> Serial No, <br /> Capacity Gal.,Weights &Measures No. <br /> J <br /> Equipment Parking Address - <br /> 2. 0 PUMPER YARD { <br /> For July l• June 30, 19 I• <br /> No. of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST - R.S.or R.C.E.No. i <br /> R.S.or R.C.E.Name Test DatefTime .. <br /> Test Location . <br /> q, ErSANITATION PERMIT - <br /> ation <br /> Job Address/Loc <br /> Address <br /> Owner (] PACKAGE PLANT <br /> ErSEPTIC TANK El CESSPOOL CYLEACHING FIELD ET'SEEPAGE PIT OTHER <br /> - <br /> ErPERMANENT 0 TEMPORARY S NEW .0 REPAIR <br /> C] CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Construction <br /> Disposal Site Q <br /> No. <br /> of Units Equipment Storage/Cleaning L t on(s5 _ <br /> g• ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified , <br /> Operator Name <br /> Plant Location No. Units Served ` <br /> Plant Capacity , <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: 13 Less Than 1,1000 Sq.Ft., -[I More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Ilcation nd that the�work will be done in accordance Y�+(p5an Joaquin County <br /> I hereby certify that I h a prepared this app I <br /> ordinances,state laws d regul s of a Sm Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE- - + <br /> 1 -FOR DEPARTMENT USE ONLY <br /> Fee is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE r 0.EACH ❑ January 1 S R By Jaeuery 31 ❑ July 1&RCcery REe�lyIT <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE MITTED - AMOUNT . <br /> ( Y <br /> FEE <br /> LESS <br /> PRORATION'�- <br /> PLUS <br /> PENALTY <br /> OTHER { 1 <br /> OTHER - - [� //x0' 1 -- <br /> = Permrt No. leauan Date' , Melled Dalive <br /> Received by Date Receipt No. 9$201 <br /> APPLICANT—RETURN ALL COPIES f0: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 f.HAZELTON AVE.,P.O.Box 2008 S O <br /> N, <br /> 1 <br />