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' Applications Will BeProcessedWhen Submitted Properly Completed. Be Sure To SignTheAppncano. ; <br /> APPLICATION �,S�, Z.- <br /> (For Non-Transferable,Revocable, and Suspendable) .SEPTAGS'rr- <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Applicati is hereby mad to on business a jurisdictional area of.t San Joa in Local'Health District <br /> Business Name (DBA) � ,' _Address ! <br />' I- Address - <br /> z Owner <br /> 4 <br /> Firm Partners, Addresses and T p one,Julmbers <br /> IL Business Telephone No. �� _iEmergency Telephone No 4:, <br /> a <br /> Contractor Licence No. . <br /> Title - Date <br /> Applicants Name (Print) , <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) <br /> ' License Renewal No.Lic <br /> Serial No. CAL. License No. CAL. ' <br /> Capacity Gal:;'Weights &Measures No. <br /> Equipment Parking Address" _ .a.,.•�-- �.� a .�.. . --- -e«-•�-_- - -..- --x-- <br /> . <br /> I 2. ❑ PUMPER YARQ_.......,.-_..,.-......,... <br /> For July 1 June 30, 19 ! <br /> No. of Vehicles Stored. <br /> i <br /> No. of Chem icalToilets-Stored—� <br /> 3. ❑ PERCOLATION TESTS ► <br /> R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name 1 <br /> Test Location + Test Date7Time <br /> 4. ❑ SANITATION PERMIT <br /> �A;rj I V1 <br /> J %ob Addr s Location <br /> Owner`f e1-02 j6eA.)� z"�4cJdress: i <br /> ❑ SEPTIC;TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT € <br /> 13 1 PEAMANENT ❑ TEMPORARY ' ❑ NEW <br /> ;IREPAIR+..-�• �0SOTHER <br /> e <br /> �. <br /> S. ❑,CHEMICAL TOILETS For-July 1,-June 30, 19 ii g <br /> Type Construction Z I ( Disposal Site t <br /> i, <br /> - E ui men4 Stora a%Cleani'n Locatioh(s}"""" <br /> No. of Units' ,—. q p 9- _ 9 � ( 1 <br /> 6. ❑'PACKAGE_ TREATMENT PLANT For July 1,-Jurie 30; 19 -- a <br /> k Where"Certified <br /> Operator Name r <br /> 4 -..".— w.•--•-i-.+--sae..... s ." ..k•. - m.. it F <br /> r . • <br /> Plant Location T a F <br /> Plant Capacity � : No.Unirts,lServei}. 't <br /> 7. ❑ LAUNDRY For July 1, -June 30"'1 <br /> SIZE: ❑ Less Than 1,000.5q. Ft., ❑,TMore'Than 1',000 Sq-Ft. s ! <br /> -4. , 1 •,E <br /> ❑ DRY CLEANING, Chemical's Used/Amount/Mb 4 , <br /> � x I <br /> D I hereby cee rtify that l have epared this aOlicati d tha the work will 6e done-in accordance with San Joaquin County <br /> f ordinances, state laws, and rules gu t San J quin cal Health District. <br /> is Y <br /> APPLICANT'S SIGNATUREX° + I <br /> tV ' <br /> r t I 4� ,` <br /> FOR DEPARTMENT USE ONLY ',• <br /> F' 4 + .� <br /> Fee Is Dile: ❑ ANNUALLY _ ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑.July�1 &Received 8y July 31 s <br /> _ REMIT <br /> ` BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 13ASE EXPLANATION DATE'."-^`• ,,;+. DATE REMITTED 'i AMOUNT <br /> �r FEE <br /> LESS <br /> PRORATION <br /> PLUS k <br /> PENALTY } <br /> OTHER <br /> 11L 7 <br /> OTHER <br /> Received'by Date 'Receipt No. Permii No- _—ti., `Issuance Date "".-"1661 E.HAZELTON AVE.,P.O.Bo Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONME14TAL HEALTH PERMITISERVICES -w.. STOCKN,CA 95201 <br />