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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION' <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE i <br /> _ ENVIRONMENTAL HEALTH PERMIT .� <br /> UQUIP WASTE <br /> Application is hereby made to carry oD but In he jurisdictional area of the Joaquin Local Health District „i <br /> F Business Name(DBA)�.� __��221.5l1� �a"�s Address <br /> I <br /> Owner__ +• Address ) <br /> g Firm Partners,Addresses andel TLele hone Numbers i <br /> g Business Telephone No. & " g`O? Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) - .Title. .Date I <br /> _ Please check Applicable Category(1-7)and FRI In the RegWr nformaaon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, - June 30.19-- Disposal Sites 1 <br /> Description(Make/Yr.,Color) <br /> Serial No.__ _ CAL.License No. AL.LAenawad No. <br /> �N tri � 4'.'! <br /> � <br /> Capacity _—Gel.,Weights 6 Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,19 - Y <br /> No.of Vehicles Stored -- - <br /> - No.of Chemical Toilets Stored (j <br /> �3. ❑PERCOLATION TEST �t ' <br /> R.S.or R.C.E.Name _ _..--_ R.S.or R"C.E.No. I <br /> Test Location <br /> Test Date/Time.. <br /> 4. ❑ SANITATION PERMIT rC -zb0/ <br /> ,oe� <br /> Job Addressq ocation T <br /> + <br /> Owner ./2 '4�'� Address <br /> J9 SEPTIC TAN0'ZESSP06L7—J5-LEACHING FIELD—06'-SEEPAGE PIT--O-PACKAGE-PLANT <br /> 11PERMANENT ❑TEMPORARY JR NEW ❑ REPAIR ❑OTHER <br /> _ 5. ❑ CHEMICAL TOILETS For July 1,-June 30,19 s ^� <br /> Type Construction Disposal!Slth./w��t 1 <br /> No.of Units Equipment Storage/Cleaning Location(s)_ <br /> 5. ❑PACKAGE TREATMENT PLANT For July 1,-June 30,19 •y <br /> ( - Where Certified <br /> Operator Name I <br /> Plant Location <br /> Plant CapacityN�.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 /> ❑DRV CLEANING,Chemicals Used/AmounVMO. <br /> Nome pwder c:tixncgd ngant'crinnanne carNtleeMa}oacwing:'T cerlY,Yth :aIftC pctOrn.anuol.tllewnrkfsrwdlcMAFe pmmals lssced.l sllstln�temp{oy any person <br /> fn such manner a;to buame wbi xa Ic'Ve mews ctlmpenszlkn;rr•F a Ce;i(;,rr,t' + <br /> C"tractoi s au's-f0':ee^-r:u, ;d•:.:rs T.) °1?,.+ v :' :�;. ",:,71 fig/:'.:.'.:n Vac p2+'.rinallCO 0:the 7+Or�for Nhttl tills permit is ISSUetl,I Saili <br /> employ pers0n5 a;:Jic.-i:c ex.,:nati:�,.3;j:u;5 :�..:a.i._:�a::...:::..... <br /> t <br /> I hereby certify that I have prepared this application end th t the work will be done In accordance with San Joaquin County <br /> ordinances,state laws•and rules a d re_qul ns o the Squirt Loca lth rice. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY 4t. mow; <br /> _ Fee Is Due:❑ANNUALLY ❑PER UNIT ❑PER SITE ❑EACH ❑January 1 6 Received By Janwry 31 ❑July 1 a Reteiv REMIT my 7 <br /> !BILLING REIAyI7TANt Y:� f1A420UNT DUE CHECKED <br /> BASE E%pLANA710N <br /> DATE- tVATE "REMITr�b. (D AMOUNT <br /> FEE <br /> ' LESS <br /> PRORATION <br /> PLUS -- <br /> PENALTY <br /> OTHFR -- <br /> r + t OTHER <br /> • _ - - ' 163 _ <br /> Tiicei <br /> vsd Dy Date Receipt No. <br /> "Permits ssuance to ailed Delivered <br /> APPPLICANT-RETURN ALL COPIES TO'- ENVIaONMEMAI HEALTH PERIa!>;^SERVICE$ 1802 E NA2ELT64 AVE.,P.O.ave 7009 aTOCKTON,CA 082pt <br /> 7 <br />