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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> :x --• (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application isy made to rryon busiiapss in/the jurisd' lonaI area of the San Joaquin Local Health District <br /> Business Name (0 )y _ �" �"�+� � Address SVca <br /> 7 L Z a� <br /> aOwner " Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> $ Business Telephone No. �6$ �1 O 5' Emergency Telephone No. <br /> Contractor Licence No. . . - 0 <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and Fill In the Required In orma9on ,J <br /> U. ❑•PUMPER.VEHICLt PERMIT REGISTRATION (FOR EACH VEHICLE) (� <br /> For July 1, _ June 30, 19 Disposal Sites ^ <br /> .Description(Make/Yr., Color) • — •A V <br /> Serial No. .s CAL License No. CAL.License Renewal No. <br /> Capacity~ ' ' ' Gal.,Weights &Measures No. — - - - <br /> t Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, • June 30, 19 <br /> No. of Vehicles St6red ISI <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 /> TestaLoc�0tion Test Date/Time <br /> 011 <br /> 4. � .SANITATION PERMIT <br /> Job Addre Location I . 0 Lj '^�e^"tAx • 4'/ <br /> e -� Address � C20+!G"3"". <br /> VPTIC TANK 11 CESSPOOL LEACHING FIELD III! SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW L111i ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site t1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 if <br /> Operator Name t Where Certified <br /> Plant Location I <br /> Plant Capacity a1`•+ No. Units,Served <br /> 7. 13 LAUNDRY For July 1;-June 30, 19 � 411`1= .,4 <br /> 1• <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.,_*p," <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. 1 1 <br /> �' •� ��... a �s 1 <br /> is Z4 <br /> � f <br /> I hereby certify that I have prepared this application and-that the work will be done in accordance with San Joaquin unty <br /> ordinances, state laws, and rules en gulations of the an Joaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE X ---- <br /> /CA <br /> FOR DEPARTMENT USE ONLY t(/(//� - <br /> Fee Is Due: 13 ANNUALLY EJ PER UNIT ❑ PER SITE El EACH ❑ January 1 a Receivetl y OLary 3 July 1 i e oivw By July 31 <br /> REMIT <br /> BASE- EXPLANATION BILLING REMITTANCEf MOUNT DUE CHECKED <br /> yy DATE DATE REM ITTE �+ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER /1 r—� <br /> V �✓� 1 <br /> Received by Date Receipt No. Permit No. lsauen a Date Mailetl. livered <br /> -_-.._..._ - �....,...�.....ra ..—...e......,.eev,nee -1. .,om mu evv en a.mnv ernrrmu ee Daum <br />