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APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to Carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> SSiness Name (DA) '� WOO? Address <br /> B �� rrq _=rs7ntt��d <br /> Niter Address <br /> I Partners, Addresses and Telephone Numbers t� <br /> .iness Telephone No. 444 - 97 Emergency Telephone No. <br /> infractor Licence No. kyr Z /J - <br /> Jicants Name (Print) OF t2 Oa7) Title. �"'�'-� Date <br /> tr Z-9L <br /> Ise cheek Applicable Category (1-7)and Fill In the Required Information O <br /> —0 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) - <br /> :r July 1, June 30, 19 Disposal Sites <br /> cription(Make/Yr., Color) <br /> Tal No. CAL.License No. CAL License Renewal No. <br /> Ipacity Gal.,Weights & Measures No. -- <br /> ipment Parking Address <br /> _❑ PUMPER YARD <br /> tr July 1, June 30, 19 <br /> - of Vehicles Stored <br /> of Chemical Toilets Stored <br /> `❑ PERCOLATION TEST <br /> S. or R.C.E. Name R.S.or R.C.E.No. - <br /> I Location Test Date/Time — -- -- <br /> -❑ SANITATION PERMIT <br /> lb Address/Location Al Mw y -j !i lyz) �e <br /> net Address_�4rrLF <br /> SEPTIC TANK ❑ CESSPOOL Jk LEACHING FIELD .r SEEPAGE PIT ❑ PACKAGE PLANT W <br /> TPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER d <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Ie Construction Disposal Site <br /> of Units Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> erator Name Where Certified <br /> `nt Location <br /> rant Capacity No. Units Served <br /> ❑ LAUNDRY For July 1, -June 30, 19 <br /> :E: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 'FDRY�464AWA ,r,C/1nomicgls Used/Amount/MO <br /> r <br /> msuch manna as In h„ _ - <br /> Cont•aamr'a t,;rinq . u pa wl...,r.._ <br /> employ pcu,aes_ <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 regulatio(Rs�- the, an Joaquin Local Health District. <br /> "-PLICANT'S SIGNATURE X `te3-��il - — <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:❑ ANNUALLY ❑PER UNIT ❑ PER SITE 11 EACH ❑ January 1 S Received By January 31 ❑ July I It Received By July 31 <br /> REMIT <br /> BASE" EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT/_ <br /> FEE <br /> �5/ cv <br /> - - c.� <br /> aW LESS _ <br /> PRORATION 1 - <br /> nus <br /> PENALTY <br /> OTHER <br /> a. OTHER <br /> _R natived by Date Receipt No. Permit No. Issuance Date Milled I� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES lent E.HAZELTON AVE. . .boa ass STOCICTON,Q%201 <br />