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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. l <br /> APPLICATION /�/ 3 <br /> r (Fdon-Transferable,Revocable,and Suspendable) - SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herby made to carryon busir� !s in the jurisdictional area of the San.JDaquin Local Health District <br /> q Business Name(DB ) L ``'` " Address ( O, /3�`� / 9 <br /> FZ <br /> Owner—A - 1 G Lam_ Address r //"y Com- W�If <br /> Firm Partners, Addresses and.Telephone Numbers, –p <br /> 9: Business Telephone No. y 'r Emergency Telephone NO. <br /> Contractor Licence I <br /> < � eiS...�/ �. Date <br /> L Applicants Name (Print) Title <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) 4– <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> �v <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 R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 0. ❑ SANITATION PERMIT' . <br /> Job Address/Location _ '-f / �L/ -b'G—/CI- L7/�/, <br /> Own Add/a <br /> 1:1jLEas <br /> SEPTIC TANK CESSPOOL IEi� ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0 PERMANENT 13TEMPORARY ❑ NEW . ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS •For July 1,-June 30, 19 <br /> Type ConstructionDisposal 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. Fl. <br /> Q DRY CLEANING,Chemicals Used/AmoynVMo. <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,and rples and re lation f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` �.! l` <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI-r ❑ PER SITE '❑ EACH ❑ January 1 S Recelved By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE ,EXPLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> DATE' DATE REMITTED �} AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ... <br /> PLUS <br /> PENALTY Q — <br /> OTHER .b1.3 BO <br /> OTHER T <br /> Received by Date Receipt No. Permit No. Issuandf,Date Mailed erect <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.So.2009 OCKT0N.CA <br />