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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> APPLICATION I` <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> AppI catjoy hereby ma to carry on bLEI ness in the sdictional area of the San�aqui �` th Dist 1 <br /> Ai�nT_• �J Qp Address <br /> wBusiness Name (DO�,j•) <br /> Address <br /> Owner d ' <br /> Firm Partners. Addresses and Telephone Numbers w ! <br /> Business Telephone No._9,6x S'C Emergency Telephone No. I <br /> j Contractor Licence No. Date ' '� �� �y <br /> Applicants Name(Print) — Title �•+ <br /> Please chedt Applicable Category (1-7) and Fill in the Required Information <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,_ June 3O, 19 Disposal Sites <br /> Description(Make/Yr.,Color)~"E CAL.License Renewal NO. <br /> Serial No, �' CAL.License No. _ - <br /> Capacity Gel.,Weights & Measures No" i <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1. +June 30•'19 <br /> No. of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST'"�'�'� <br /> R.S. or R.C.E.Name' 4 _ _^ •' R.S.or R.C./No: <br /> Test L Cation Test Date/Time - <br /> I. <br /> Test <br /> PERMIT AV A �f• _ _ <br /> Job Address/ o ton <br /> Owner Address.�`1 Q5o <br /> ❑ SEPTIC TANK 13CESSPOOL 11LEACHING FIELD WE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW EPAIR E3 OTHER <br /> 5. ❑ CHEMICAL.TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Looation(s) 1 <br /> a. ❑ PACKAGE TREATMENT PLANT For July l l June 3O, 19 { <br /> 1 WMeTe-Certified <br /> Operator Name I <br /> Plant Location + - 1 ) <br /> No.Units 3 <br /> Plant Capacity e'rvietl <br /> i 1 <br /> 7. ❑ LAUNDRY For July 1,-June 30. 19 r.• •y./ •— <br /> SIZE: ❑ Less Than 1,000 Sq.Ft.. ❑ More Than.1,000 Sq. Ft. <br /> L ❑ DRY CLEANING,Chemicals Used/Amountlmc. ' _� <br /> i - <br /> i that the work will be done in accordance with Sen Joaquin County <br /> 1 hereby certify that 1 have prepared this application Enc <br /> ! ordinances,state laws,and rule�Rtend regul Iggs of I paJoaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> P <br /> FOR DEPARTMENT USE ONLY 4 1T' <br /> 1I. Fee Is DW:❑ ANNUALLY 13 PER UNIT ❑ PER SITE ❑EACH ❑ Jeouary 1 s Received By January 31 ❑ July 1 6 Recaiv d BAly JulyREIT <br /> J1 <br /> 1 BILLING REMITTANCE $ AMOUNTOVE CHECKED <br /> 1111 DATE DATE REMITTED AMOUNT <br /> BASE EXPLANATION <br /> E <br /> PEE 4 <br /> I <br /> • LESS <br /> PRORATION 1 ,� <br /> w <br /> PENALTY '1 <br /> I OTHER 1l^^ <br /> OTHER <br /> TSD 4-a Z4 <br /> Received DY - Dale Rewlpt NO. <br /> Porleil No. I to fled Delivered <br /> AVE <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAWTMERVICES 1e01 E.Mp2ELTO9e'(P OC � I V Apr <br /> �� <br />