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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 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on bysiness in the jurisdictional area of the San Joaquin Local Health District <br /> v;Business Name (DBA) HNN012. CL�2N, Address /9/9 6/L./97�0 Z'/171J/7_t QL✓� <br /> i Owner Address.. <br /> Firm Partners, Addresses and Tele hone Numbers <br /> a. Business Telephone No. y�7— J� Emergency Telephone No. `IL/t.—/3l/s- <br /> a <br /> � Contractor Licence No. � <br /> �APPlicants Name (Print) .DHl�/NfF :5YY) I rH f,' ,4M -i E""17 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 <br /> For July 1, June 30, 19 r <br /> No. of Vehicles Stored <br /> No. Chemical Toilets Stored <br /> o <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name k'c, H�1H�E,ti- C. INf-f LlJQ� R.S.or R.C.E. No. Z9 ZSS <br /> Test Location Nr nrn�r �i'1 F "--1=> Test nate/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ 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 --I <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 `S! <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 /> �Q <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County y <br /> ordinances, state laws, and rules and regulatiQ41s,of the San Joaquin Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE X ���x, <br /> c/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> h/ AMOUNT <br /> FEE 7251 ' , <br /> LESS CNV <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 Receiv by Dat Receipt No. Permit No. Issuance Date Mailed DeliveredLIC <br /> APPA T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sm 2009 STOCKTON,CA 95201 <br />