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. Applications Will Be Processed When Submitted Properly Completed. Be Sur o Sign The Application. ( , <br /> ' APPLICATION �c f qa <br /> (I on-Transferable, Revocable, and Suspendabit SEPTAGE <br /> cNVIRONMENTAL HEALTH PERMIT 1 <br /> LIQUID WASTE _J0 <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Lal H�eTalth DTi5tprlct / <br /> %Business Name (DBA)�)AI9�,.rA��% Address L /�■ <br /> ` /I Address - i1 <br /> Owner " ' M• - -_-- <br /> Firm Partners,Addresses and Tele;56ne Numbers: r--' <br /> i Business Telephone No. `�2 6,;.- A 41.�';z �. 7 emergency Telgphone 06. , <br /> Contractor Licence No. <br /> Applicants Name(Print)_�I AM � [IAAF' v*Title E`�,t�dE1.1,� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information .1. <br /> 1 <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 B 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 R.S. or R.C.E. No. <br /> Test Location ' Test Date/Time <br /> 4. ® SANITATION PERMIT - �s /� ' <br /> Job Address/Location .Q�i —�,(�.cue+� �-I _ A2 R, TeW-6 y eft'Ef, <br /> Owner - Addres$ <br /> SK SEPTIC TANK 11 CESSPOOL, g LEACHING FIELD &SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0 TEMPORARY C3 'NEW ❑ REPAIR 0 OTHER <br /> S. ❑ CHEMICAL TOILETS For Juljr 1,-June 30, 19 <br /> Type Construction •Disposals ite <br /> No. of Units equipment Storage/Cleaning Lodation(s) <br /> 6. 0 PACKAGE TREATM_NT PLANT For July 1,-June 317,'19 C <br /> E <br /> / �� Where Certified <br /> Operator Name -� <br /> Plant Location <br /> Plant Capacity No. Units Served �yyPyy <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 m /r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft." ❑ More Than 1,000 Sq, Ft. <br /> 11 DRY CLEANING, Chemicals Used/Amo�nVMo.' 1 <br /> Q <br /> Mill <br /> r <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,an <br /> 1�les and regulations of tflepan jiliaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -4/JL/}1 <br /> 0 <br /> • f •FOR DEPARTMENT USE ONLY +• <br /> Fee IS Due: ❑ ANNUALLY! 17❑ PER'UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $ REMIT C <br /> BASE 'E%PLANATION OATS DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS v <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lawan Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKT N,CA 95201 <br />