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'.PP,......... ,o ..... ..� . ..,..�o�cu vum, v „ wu r vycuT �.mnprmcu. tac au,c ,v�ryu ,im•�Ppu�mw,,. <br /> t APPLICATION <br /> • Non-Transferable, Revocable, and Suspends SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is.tiereby mad carry on business in the jurisdictional area of the San JoqUinlLopl HealtG�Distrl <br /> H Business Name (DBA) f 0 &� Address � �� CPQ-( <br /> J- <br /> - Owner (o ff Address 7 <br /> a <br /> Firm Partners, Addresses and T I phone Numbers <br /> i< Business Telephone No. (P Emergency Telephone No. <br /> a <br /> Contractor Licence No. cz <br /> L Applicants Name (Pring W 2 C t` Title Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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 Q <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 R.S.or R.C.E.No. <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Loc ttion <br /> Ow tij Address <br /> � H ��' ❑ PACKAGE PLOT <br /> L7 SEPTIC TANK ❑ CESSPOOL �ING FIELD EEPAGE PIT � / d"A_ <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAII�R ❑ OTHER A/ew X y_jy'e^� <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �! -�' r �""'� 61'�a;I <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 /> Where Certified <br /> Operator Name <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 I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, andd u1 les and regulations ol the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a ReceivendEBAyl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. _ Issuance Date Mailed Deliver <br /> APPLICANT—RETUflN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Ise1 E.HAZELTON AVE.,P.O.BO200 <br /> T 8 STCC TOtj,1'19�a1 <br />