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I Applfcatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable.Revocable,and Suspentlable) SEPTAGE I <br /> ( ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati. 's eby car b i ssm thejurisdictional area ofthe JO nLocal HII isirict <br /> p 8usine (DBA Addreit fzz <br /> i Owner CK (y <br /> " � 7vS 36 <br /> Firm Partners,Addresses d Tele)h e Numbers +-- <br /> Business Telephone No. Emergency Telephone No- -• - - 1 <br /> Contractor Licence No. <br /> �Applicants Name (Print) - Title Dete �"�6 Gla <br /> Please check°Applicable Category(1-7) and Fill In the RegWred Information <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30. 19 __ Disposal Sites <br /> Description(Make/Yr.,Color) -. <br /> cn <br /> CAL.License No. CAL.Licse Renewal No <br /> Serial No. . <br /> I Capacity Gal.,Weights&Measures No. <br /> r Equipment Parking Address <br /> 2. 0 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored No,of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST <br /> 1 R.S.or R.C.E.Name _ - R.S.or,R.C.E.No. <br /> + <br /> Test Location i Test Date/Time <br /> ( - <br /> e. 9—VANITATION PER TI/ <br /> 1 Job Address/LOcatio / W <br /> i Owner �� 1 Address <br /> 0 SEPTIC TANK 0 CESSPOOL 0 LEACHING FIELD 0 SEEPAGE PIT 0 PACKAGE PLANT <br /> 0 PERMANENT 0 TEMPORARY .�0 NEW 0 REPAIR 0 OTHER <br /> j 5. ❑ CHEMICAL TOILETS Fdr July t•Z�Jun 3Q 19 <br /> Type Construction Disposal Site ---j <br /> No.of Units Equipment Storage/Cleaning Location($) <br /> i 6. 0 PACKAGE TREATMENT PLANT �pr July 1,-June 30. 19 <br /> 1 Where Certified <br /> Operator Name ' <br /> Plant Location - <br /> Plant Capacity No.UnitsSsrvad <br /> 7, 0 LAUNDRY For July 1,-June 30.1b <br /> SIZE: 11Less Than 1,000 Sq.Ft., 01 More Then 1,000 Sq.FL (S <br /> 0 DRY CLEANING,Chemicals Used/AmounVMO. <br /> a tic n and that the work will be done in acc danb`�'h San Joaquin County <br /> I hereby certify that have pre this pp 1 - --f <br /> ordinances, state laws, and 1-106-1111 r uletic of e n Joaquin Local Health District- <br /> APPLICANT'S SIGNATURE X <br /> ,. FOR DEPARTMENT USEO L <br /> 1 Fee Is Due:13 ANNUALLY C) PER UNIT 0 PER SUE 0 EACH 0 Jl d Racewa0 BY January 71 July 1 6 Rete �CREM JuW 31 <br /> BILLING REMI $ AMOUNT DUE CHECKED <br /> BABE EXPLANAT DATE DA REMITTED - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY '•� <br /> 4 OTHER <br /> OTHER <br /> I ace t Na "mi N ante D to ailed eliveree 1 <br /> ! � Leet E.HA2ELTON AYe..P.O.sox 3009 8TOGXT .CA$5201 i <br /> L. <br /> APPLICANT-RETUIIN ALL Cap"TO: !f.NYIROMa1ENTAL HEALTH PEBMIT/$LRY s <br />