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nyp..=.wra v,.. oc r.., vnmr u „rr rr vycuy �.vurprcrca. oc u. uiyu r uc nyyiwauon. <br /> APPLICATION `✓V <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ` LIQUID WASTE <br /> Applicati Is her by a ato car on b Aass in the jurisdictional area of the San Joaq Lo Heal District <br /> Business Nam (DBA) ��yztw i/f"//'�/ Address r+ % C �� <br /> Owner r rl�t Address Bili V__ <br /> �.Firm Partners, Addresses an a gph�ngf,�,umbars <br /> aBusiness Telephone No. �f :� Emergency Telephone No. — Z <br /> Contractor Licence No. <br /> �c Applicants Name (Print) N Title Date <br /> \Please check Applicable Category (1-7) and Fill in the Required Information 9`"J <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) oI <br /> For July 1, June 30, 19 Disposal Sites T� <br /> ` Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> r 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 R.S. or R.C.E.No. <br /> Test Location Test Date[Time <br /> J9. ❑ SANITATION PE <br /> R70j S-= <br /> Job Address/Location = r <br /> r O ner Address <br /> - SEPTIC TANK ❑ CESSPOOL I(LEACHING.FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT n <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER �C <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ` Type Construction Disposal Site C-A <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> ` 7. ❑ LAUNDRY For July 1, -June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> //vIN <br /> 1 herebycertify that I have ared.this a plication and that the work will be done in accordance with San Jo gl In County < <br /> Y P P <br /> V ordinances, state laws, a u and reg <br /> ulati of the San quin Lo I Health District. <br /> 1 <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION AMOUNT DUE' CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> V LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ` OTHER <br /> OTHER �v <br /> LRecei�D Da Receipt No. Permil o. Issuance Date Mailed Delivered <br /> -_......_ __ ... -L-.--__ _.....__...._.._.. .._.............--------- .__._ ...-_._.... ...� ..,. ._......_.... .�., Cil <br />