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• e , APPLICATION <br /> ( Non-Transferable, Revocable, and Suspendable' SEPTAGE <br /> cNVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby/made to carry on business in the jurisdictional area of th San Joaquin Local Health District <br /> H Business Name (DBA) Abj_;* f <br /> 5 <br /> Ti97�E s .au� �G• Address v 6G .�o�,�= Cid• � 5�= <br /> L <br /> aOwner---_ --_ Address <br /> u Firm Partners, Addresses and Telephone Numbers - <br /> CL <br /> Business Telephone No. 5`a7— ..2 Z 7 1 Emergency Telephone No. p <br /> Contractor Licence No. ---ADR ��i9II9 <br /> Applicants Name (Print) -__ Title ._-- ---_ Date - t <br /> Please check Applicable Category (1-7) and Fill in the Required Information ENVIRONMENTAL HEALTH <br /> 1. Cl PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) PERMIT/SERVICES <br /> For July 1,_ .- -_._ _ June 30, 19 _--- Disposal Sites ----------..--------------.. .__ -- _ - -.---..._.._._._-._—•--- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. -__.._ ___ CAL. License Renewal No. <br /> Capacity __. . Gal., Weights & Measures No. ___-- --_ _------____._ _ _ __ ............ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,._.._ _. June 30, 19 <br /> No. of Vehicles Stored - <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name k1;Ae 9 � 1e R.S. or R.C.E. No. 0-779YTest Location A 5— 87- 6 Test Date/Time--_ <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _._ _ Address-- <br /> 0 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19-_ — <br /> Type Construction Disposal Site <br /> No. of Units ___ - _ Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name _ —__—_._____.__.__ —_ _ Where Certified <br /> Plant Location -- <br /> Plant Capacity No. 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> I hereby certify that 1 tMve prep�areths aTiotn and at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, n r eslahe Sa uin Loca ItAPPLICANT'S SIGNATURE XFOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> � AMOUNT _ <br /> FEE 1 \C_) c--) . (.:vo SU <br /> -- <br /> LESS liv •� r(. �+�. <br /> PRORATION c I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered I_ .- <br /> �— APPLICAET RN ALL COPIyS TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 '3TOCK1 ON,CA 95201 --� <br />