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Applicatloris Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. { <br /> - i <br /> r APPLICATION µ� <br /> ` (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE S <br /> -Application is hereby made.to Carry on b siness in the jurisdictional area of the San Joaquin-Local Health District <br /> F Business Name (DBA) dam+A�I I PA,e�l S l� So�1/S Address .P9 BD X I4 ZT_0 t1 9.5:)-o/ <br /> z Owner .. m � A.. PQ R-� LS N PAE-s- Address L _ <br /> a - rl �O <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 6•'re — 9 La-7 Emergency Telephone No, `t <br /> Contractor Licence No. �zS <br /> Applicants Name (Print)—rte°—d? YQ Gclortl D Title Date 1'2 q <br /> i <br /> Please check Applicable Category,(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (� <br /> f For July 1, June 30, 19 11 Disposal Sitesy <br /> Description_Make%Yr., Color) .. .-' 4 <br /> 5p <br /> f Serial No. .IL -.. CAL. License No. CAL. Lice.se Renewal No. �+ <br /> I Capacity if Gal., Weights & Measures-No.---w- - — (� <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I , <br /> For July 1, June 30, 19 i <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 /> 4. 0 SANITATION PERMIT <br /> Job Address/Location C r=Af7 ak ST eoiV CA m PO <br /> Owner -7Z6 Address PO ,ale Am Po <br /> 19 SEPTIC TANK ❑ CESSPOEOL OLEACHING-FIELD yK� SEEPAGE PIT ❑ PACKAGE PLANT d <br /> ❑ PERMANENT ❑ TEMPORARY ElNEW ". ksl REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction , Disposal Site <br /> It No. of Units Equipment Storage/Cleaning Location(s) <br /> k. 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location �M <br /> r Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Tharfi1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> It y y r <br /> � r <br /> F 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.4and rules and regulatio San Joaquin Local Health District, <br /> I APPLICANT'S SIGNATURE X <br /> 4"— FO 1 PARTMENT-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 /> REMIT <br /> &ggBILLING, * j REMITTANCE $ <br /> BASE, EXPLANATION r-„ - AMOUNT DUE CHECKED <br /> ATE ---DATE - - REMITTED AMOUNT <br /> /� <br /> FEE Of <br /> t LESS i <br /> PRORATION <br /> PLUS <br /> k..;, PENALTY <br /> y <br /> OTHER II _ � � r t _ <br /> - 1 <br /> E <br /> OTHR I <br /> F= :�: .ire.---- � .�• - _ , <br /> Receiv y - Date1' Receipt No. 7 '- Permit No.r - Issuance Date Mailed Delivered <br /> AP LICANT—RETURN ALL COPIESp:TENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKY ,CA. 5201 <br />