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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,. <br /> APPLICATION <br /> r✓!" (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby detocarry on business in the urisdlctional area of the San Joaquin Local Health Dist ict } <br /> 1A Business Name(DBA) 2 E 1�C Addreoss.�los S IL�E.l°T <br /> 1. /_ 1 • n �/ �! Address �70s S � �� <br /> 07- <br /> ;Owner 7 f <br /> Firm Partners,Addresses and Telephone Nulnbe�s <br /> Business Telephone No. 7 <br /> I .�Col Emergency Telephone No. <br /> Contractor Licence No <br /> Applicants Name--(>3rmt) i. Title E.ST Date�. <br /> Please check Applicable Category{1 )and FIII in the Required Information - <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 5 <br /> Description(Make/Yr.,Color)• <br /> Serial No. I CAL.License No. L. License Renewal No. <br /> Capacity !Gal.,Weights S Measures No. <br /> Equipment Parking Address <br /> 2. 0 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST N <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time v� <br /> 4. J9 SANITATION PERMIT ! Q. <br /> Job Addre ocation <br /> O er - Address <br /> EPTIC TANK CESSPOO LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> PERMANENT 0 TEMPOR�Y ArNFW 0 REPAIR 0 OTHER <br /> 0 W "' <br /> Construction CHEMICAL TOILETS For July 1,-June 30, 19 <br /> -.' . •^•^- - Disposal•Site ' t <br /> I I ' <br /> No. of UnitsT Equipment Storage/Cleaning Location(s) ; <br /> 6. 0 PACKAGE TREATMENT PLAf�}NT For July 1,-June 30; 19 <br /> Where Certifiedt <br /> Operator Name ', STA sr1:�� IE l:. 1�'L 3 .�•i " i <br /> Plant Location t <br /> Plant Capacity !j No.Units Served <br /> 7. 0 LAUNDRY For July 1,-Jul6 30.19 , <br /> SIZE: 13 Less Then 1,000 Sq.Fptp., d More Than 1,000 Sq. Fl. <br /> 0 DRY CLEANING,Chemicals Used/Amount/Mo.- <br /> ' i 1 i <br /> I hereby certify that I have prepared this application and that the work will be.done'fn' h�rdance with San Joaquin County i <br /> OrAlnences:state lawsAnd ,' <br /> nd regul¢tionsof thp�n Joaquin LOWI Health District.APPLICANTS SIGNATUR <br /> ' FOR DEPARTMENT USE ONLY 41 --7- <br /> D <br /> y- <br /> } [F <br /> F6e'Ie DUs:E3 ANNUALLY PER UNIT Ila PER SITE E3 EACH ❑ January 1 a Reeeivatl By January 31+:! ❑ July 1 8 Recelvatl By July 31 <br /> I, t REMIT I•' <br /> EXPLANATION BILLING REMITTANCE ,(`1 It .AMOUNT DUE CHECKED <br /> ' BASE DATE DATE REMITTED t AMOUNT <br /> 1 FEE . <br /> t PRORATION <br /> !!!� PLUS <br /> PENALTY <br /> OTHER j it <br /> ( OTHER <br /> Ra0ryDate I Receipt No. <br /> e0 OY o. 1 ante to Mailed Oeli <br /> k P <br /> 'I APPLICANT—RETURN ALL COY Es TO:�ENVIRONMENTAL HEALTH ERNIT/SEIIVICEB '1801£.NAZELTON AYE,PA.boa 1009 5r ON,C <br />