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€ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION J <br /> (For Non-Trandsterabl Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address 2t ale Alf"lle 1 <br /> aOwner ��i?°%��/l�' �G!f/ �� Address -� V <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> 4 <br /> Contractor Licence No. <br /> Applicants Name (Print) Title 0 _^„•”,Ur.�/ rDteG_;t._Enmm <br /> � <br /> Please check Applicable Category (1-7) and Fill in the Required Information 2&3 So, 0,-o J SfoCltt 3^ �3iif. 55205' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (-6-�It;1 a"{5 C l,r C C?P' !-;c, 76717z <br /> For July 1, June 30, 19 Disposal Sites v r, <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &.Measures No. <br /> k Equipment Parking Addressy ^` - <br /> 2. ❑ PUMPER YARD F <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST -` <br /> F R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMI <br /> Job Address/Locatio <br /> caner�A- �-�—� Address 'X <br /> SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE LANT <br /> PERMANENT ❑ TEMPORARY 19NEW ❑ REPAIR N" ❑ OTHER <br /> f 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f . <br /> Y <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 Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> f 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 /> INAk <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 le nd regulations of the San Joa uin Local Health DisiCict. SCff1:1C <br /> i f• �7p✓ g r ! <br /> APPLICANT'S SIGNATURE X "`' °.. „ 95205 <br /> N. pg C cin,i .or's!.;, +-'2671771 <br /> FOR DEPARTMENT USE ONLY <br /> 4 -Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> h BILLING REMITTANCE REMIT <br /> k BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE irr7 <br /> LESS. <br /> PRORATION <br /> PLUS " 1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. " --Permit No. ` Issuance Date - Mailed Deliver d <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES, 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTO ,CA 95201 <br /> -- -- <br />