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Applications Will Be Processed When Submitted Properly completea. tieaure Iv 0±911 rIla^rr^- <br /> _ APPLICATION <br /> (For Nan-Tranifei rable Revocable,and Suspendable) SEPSAGE <br /> y' ENVIRONMENTAL. HEALTH;PERMIT <br /> LIQUID WASTE <br /> San Joaquin Local Healtsi strict: <br /> Application is hereby made to carryon business in the jurisdictional area of the . <br /> w Business Name (DBA) Address <br /> - Address <br /> z Owner <br /> Firm Partners, Addresses and Telephone Numbers <br /> Ayr___ <br /> �— Emergency Telephone No. _ <br /> CL Business Telephone No. — <br /> Contractor Licence No. <br /> Date <br /> • to <br /> ,Title <br /> L Applicants Name(Print)— FL�Q _-Wco E7 <br /> Please check Applicable Category (1-7)-and Fill in the Required Information•Q. ; � ntj 'I „} <br /> 1. ❑ PUMPER VEHICLE PERMIT;REGISTRATION (FOR EACH VEHICLE) <br /> For`July 1,- 19 <br /> Is ..- _.- —Disposal Sites - — <br /> �� " June 30, — <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. <br /> CAL. License No. <br /> Capacity r Gal., Weights &Measures No. <br /> Equipment Parking Address - <br /> 2. ❑.`PUMPER YARD <br /> For July 1, June 30, 19 <br /> � <br /> s <br /> No, of Vehicles Stored " 4 • ,, <br /> No- of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or.R.C.E.No. <br /> R.S. or R.C.E. Name <br /> A Test Date/Time <br /> Test Location I <br /> 4. ❑ SANITATION PERMIT <br /> 'Job Address/Location 140. . <br /> Owner_ .rr �1l�t1/�AS tI }_ Address w. S7ta :1 <br /> 1L1f1N4 - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING;FIELD SEEPAGE PIT ❑ PACKAGE PLANT. — 4� <br /> i 11 PERMANENT ❑ TEMPORARY ❑:NEW REPAIR ❑ OTHER r- <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> { 4. <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ( , <br /> a Where Certified <br /> Operator'Name — y <br /> Plant <br />• Plant CapacityLocation <br /> q <br /> 7. 13 LAUNDRY , For Jul , <br /> t No. Units Served .. <br /> July 1 -June 30 19 <br /> i .SIZE: ElLess Than 1,000 Sq.-Ft.,1- s� More Than 1,000.Sq.-Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' w <br /> 4,. _ _ mow.« -I�•"�.f .`'. i ,T v -k , <br /> i E- <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 law's, and rules and regulation the San Joaquin Local Health District.Y } <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ; <br /> r <br /> I <br /> Feels Due: ❑ ANNUALLY- __❑ PER UNIT ❑ PER SITE s ❑ EACH El January 1 &Received By January 31' ❑ July 5 &'Received By Juiy'31 <br /> � REMIT <br /> SASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> E - - t— DATE DATE REMITTED- 1 AMOUNT <br /> I <br /> 44 0 <br /> FEE .0 cQ 0 <br /> F <br /> LESS <br /> PRORATION' <br /> PLUS fi ? + <br /> PENALTY }- i. - - i' <br /> .OTHER, <br /> OTHER.._. <br /> h Date Receip4 No <br /> ! Permit No. C Issua a Date Mailed Delivered <br /> Received by <br /> �- 1664 E.HAZELTON AYE-,P.O.Box 2009 STOCKTON,CA 95201 L <br /> A0PLI6ANT—R6uRN ALL COPIES TO: ENVIRONMENTAL FIEALTH PEiiMITlSERYICES <br />