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1 t✓ / Appl atione W)!I Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suapendable) <br /> 7 <br /> 0 ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> L--I v LIQUID WASTE <br /> Application hereb made to car on b sines in the jurisdictional area of the n Joaquin Local Health Di let <br /> �isiness N e (DBA) Y carry - Q�4�+r Address�O /SafT' 767 <br /> 'tlOwner Address <br /> IJ Firm Partners,Addresses and Telephone umbers _ <br /> gBusiness Telephone No. - 3 tdr S/ O$ Emergency Telephone No. . <br /> Contractor Licence No. T�Z 7� _ <br /> L Applicants Name (Print) " —. —Title —Date —� <br /> Plane cheek Applicable Calagory(1-7)a11d Fig 1n the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1,_ —June 30, 19__ Disposal Sites <br /> Description(Make/Yr..Color) <br /> Series No. _ _- _CAL.License No. . -CAL.Liccase Renew tt No. <br /> Capacity— ——.—.—_ Gel..Weights 6 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 Chemicai Toilets Stored <br /> 3. ❑ PERCOLATION TEST -- --R.S.or R.C.E.Name— R.S.or R.C.E.No. <br /> Test Location — Test Date/Time .————. <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/JJ�aation��— <br /> Owner 4 Z 1 A _. Address.l-s—tm-9_q__ya ..,.A_ WA-Z —— <br /> ❑ SEPTIC TANK ❑ CESSPOOL E LEACHING FIELD W?WPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0 REPAIR ❑ OTHER V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> -ype Construction__ Disposal Site __ _ -��• <br /> llasi�o. of Units ___--_Equipment Storage/Clear ing Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name - .- <br /> -- - - -. .-- - ._ Whom CaAified_ <br /> Plant Location <br /> Plant Capacity —_--— _—No. Units Served -- - —__— -- — — — - - <br /> 7, ❑ LAUNDRY For July 1,-June 30, 19-- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Then 1,000 Sq.Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Nawrewwre.NlwalaSepePps —. <br /> n such ma/atnto pomaueas.u,.b.il�ecttto—.�h� c-twap�%n r..Icem tifor a �fkDerformanCeofmPwrmk rn••vktrrlthls pMmit is Issued lsaall rN.tam o a <br /> employ ALrsene seotaet to *"I abwahRe eerdfrea the fAaaW 1>t Y ny!"I ll" <br /> man's compi`.�satlon 4ws of Callternm.' M- 1 Ccrniy that in Me perWrmante p/the"ll,for whiLh this permit is issued,I shall <br /> I hereby certify that I have prepared this <br /> yyyapplication and that the work will be done in accordance with San Joaquin County <br /> ordinances. state laws.an testes= re,and <br /> fa' ns of the San Joaquin local Health District. <br /> APPLICANT'S SIGNATURE X - jpI/.. <br /> FOR DEPANTMENT USE ONLY <br /> Fee Is DW:Q ANNUALLY ❑PER UMT_❑ PER SITE ❑ EACH ❑ January/a Received By January 31 ❑July 1 a ReceneU By July 31 <br /> BASE EXPLANATION ' REIMTTANCE I S REWT <br /> M <br /> DATE DATE REITTED AMOUNT DUE CHECKED <br /> --� -- R -{-- — - - -- -- _. _AMOUNT _ <br /> I'SFEE I [�y"-�� I <br /> LESS D-F <br /> PRORATION �-- �--'— <br /> PLUS --�--- �— - - -- <br /> PENALTY _--- -- � <br /> OTHER ---�— --- — <br /> _ kS�o� S ► i }{ ---- <br /> ReCNVWay tMIB Ne.e,V No. --- <br /> APPLICAW-NW MMAtL C011Elt TOS WWMONMEWAL HEALTH PEmmr/SeRV10Ea 141"E NAIILMN AVII PA. pe N,aaon STOCKTOCA,N, <br /> _ I <br />