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Applications Will Be Processed When Submitted Properly Completed. he Sure I o S)gn I he Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspend his) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />r^ APPlication ys r me jocarrygn�s�e_intbe iurisdictional area of San aquinypcal Health DDiis`trict , <br />e Business Name (DE A/l �fj s�.c' �� µ 3PS�� �Q - . 0 - /Q-jk /^ T <br />i Owner EMI / (A ✓�"YI �i' S i Aggress f-'"�+ Nuc l4d 00 7M- c [ i'r�' [ <br />U Firm Partners. Address sand Telep ne Num � gni ' <br />C. <br />Business Telephone No. [tr=.cp ,!' Emergency Telephone No. <br />I Contractor Licence No. <br />Applicants Name (Print) 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, <br />Description (Make/Yr., Color) <br />Serial No. <br />Capacity <br />Equipment Parking Address <br />2 ❑ PUMPER YARD <br />19 Disposal Sites <br />CAL License No. _ <br />Gat., Weights & Measures No.. <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />CAL License Renewal <br />of Chemical Toilets Stored <br />Ip—3. PERCOLATION TEST <br />or R.C.E. Name Michael Erwin R.S. orR.C.ENo. R.C.E. #18625 <br />Test Location see attached Ln!, Tests te/Time 81 <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner <br />❑ SEPTIC TANK <br />❑ CESSPOOL <br />Address <br />'❑ LEACHING FIELD ❑ SEEPAGE PIT <br />❑ PERMANENT ❑ TEMPORARY U NEW <br />S. ❑ CHEMICAL TOILETS For July i, - June 30, 19 <br />❑ REPAIR <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 _ <br />Plant Location _ <br />Plant Capacity _ <br />No. Units Served <br />U PACKAGE PLANT <br />❑ OTHER <br />Where Certified <br />7. ❑ LAUNDRY For July 1, - June 30, 19 <br />SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1.000 Sq. Ft. <br />❑ r;LEANINf�G, Chemicals Used/Amount/MO. <br />I ineritu lse libK oorlt'selQnsluncmlReslheiolloyvirrW cartiiv hatinlh,performarceofClewc,.kfcrwhlchthis ermitlslaaued,lihallnotsm 1 a <br />Cwhettat'shecbme su tryccl to trorRman's ccnpePSA+jCII I]r,a. t:a1;A''. ia.— p pey nY Daman <br />"Play peraohahw ed to worAlhan'3 corm algaaa;ra s rYaa a;- '3&Q'4V: -1 eedily that in the performance of tine work for which this permit Is Issued, I shag <br />cornP�klaDon lays <br />- " I hereby certify that 1 have <br />ordinances, state laws, and <br />APPLICANTS <br />the work will be one in accordance with San Joaquin County <br />leuin Local th District. <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: <br />❑ ANNUALLY ❑ PER UNIT <br />❑ PER <br />SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 d Rece,red By July 31 <br />- - - <br />REMIT <br />BASE <br />EXPLANATION <br />BILLINGREMITTANCE <br />AMOUNT DUE <br />CHECKED <br />DATE <br />REMITTED <br />AMOUNT <br />Jr <br />4f I D,5D <br />5ex-c+e <br />1 <br />FEE <br />am <br />— PRORATION <br />PLUS <br />PENALTY <br />U �v <br />OTHER <br />5 <br />OTHER <br />Received by <br />Da <br />RecwW No. <br />Permd. No. Issuance DOM Malted Delivered <br />