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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �. <br /> ;' APPLICATION AM <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> i Applicati Is^herephy made t carryon usinass In the jurisdictional area Of the en J�quin Local I Ith District <br /> rre <br /> Business Name (DBA) n rAMI S efi r "&C Address <br /> Owner 'Address - <br /> Firm Partners, Addresses•and�l phone Numbers <br /> eBusiness Telephone No. 9 7 — Emergency Telephone No. <br /> ' Contractor Licence No. QE,rl Title Date <br /> L Applicants Name(Print) <br /> Please check Applicable Category(1.7)antl Fill In the Required Information <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> I For July 1•, June 30, 19 Disposal Sites <br /> kDescription(Make/Yr.,Color) CAL.License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights&Measures No. <br /> 1 Equipment Parking Address <br /> 2. 0 PUMPER YARD <br /> For July 1, June 30. 19 <br /> ' No.of Vehicles Stored <br /> j No.of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST R,S.or R.C.E.No. — <br /> ' R.S.or R.C.E.Name _— <br /> . Test Date/Time <br /> Test Location <br /> e, 11 SANITATION PERMIT <br /> Job Address/LocationT7�AGr <br /> ' Owner r Address 7 y ` <br /> ,X SEPTIC TANK 0 CESSPOOL r 99 LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> N PERMANENT 11 TEMPORARY 0 NEW 0 REPAIR OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 19--- <br /> Type <br /> 9—_— <br /> Type Construction - Disposal Site <br /> 4 No.of Units r Equipment Storage/Cleaning Location(s) <br /> S, ❑ PACKAGE TREATMENT PLANT IF For July 1,-June 30,19 Where Certified <br /> I Operator Name <br /> Plant Location <br /> PNo.Units Served <br /> Plant Capacity_ <br /> 7. 11 LAUNDRY For July 1,-June 30, 19 <br /> I SIZE: fl Less Than 1,000 Sq.Ft.. 0 More Than 1,000 Sq. Ft. <br /> ' t ❑ DRY CLEANING.Chemicals Used/AmounVMO. <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> 1 <br /> ' APPLICANT'S SIGNATURE X �� –­r7 C <br /> *44 <br /> L g . FOR DEPARTMENT USE ONLY <br /> ' Fee le DUe:❑ ANNUALLY ❑ PE0.UNIT ❑PER SITE ❑ EACH C3 January I&Receive0 By January 31 (]JOIY r 5 Racal FEMITBy vIy 91 <br /> BASE EXPLANATION BILLING REMITTANCE. $ AMOUNT DUE CHECKED <br /> DATE "'DATE- REMITTED AMOUNT <br /> FEE <br /> t 1 PESS <br /> RORATION <br /> PLUS s / <br /> PENALTY 74 <br /> OTHER j <br /> OTHER �{ <br /> ece <br /> ' ReceivW by _._.._. pale ,onuuiPl Na. Permit No. Issuance Dara ailed oeciveretl <br /> aura HESLTH PERMIT/SERVICES '1001 E.XAZELTON AVE,P.O.aoa 3009 OiOCKTON•Ce 55]UI— <br /> 1 \ <br />