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APPLICATION <br /> IK. (11i.Non-Transferable, Revocable,and Suspendablep.-% <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE Sj <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> tusines�lyame (()8A .� ^7 ^7Address VI <br /> Owner r"a -� Address 2, ,c O -4 P("v e !lr_ <br /> irm Partners, Addresses and Telephone Numbers <br /> welusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> .pplicants Name (Print) CS Pry Title PJ Wk P"" Date <br /> lease check Applicable Category (1-7) Ad Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> cor July 1, June 30, 19 Disposal Sites <br /> )escription(Make/Yr., Color) <br /> "Serial No. CAL. License No. CAL. License Renewal No. S <br /> Capacity Gal.,Weights& Measures No. <br /> --quipment Parking Address `1.J <br /> ,1. ❑ PUMPER YARD li <br /> For July 1, June 30, 19 ry` <br /> '4o. of Vehicles Stored <br /> Jo. of Chemical Toilets Stored ?1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> X <br /> 'est Location Test Date/Time <br /> J. ❑ SANITATION PERM`g/ ��� I; ee !/ L #'J K I) <br /> Job Add /kocatior / — L <br /> 7wner 1{Y� r L 1 e � 4 'e is tcd_ Address '2 3 ZD ISL"?' (r-e /r LO / S <br /> SEPTIC TANK ❑ CESSPOOL & LEACHING FIELD ig'SEEPAGE PIT ❑ PACKAGE PLANT 5 <br /> PERMANENT ❑ TEMPORARY XNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site i <br /> "No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> .Jperator Name Where Certified <br /> nllant Location <br /> Plant Capacity No. Units Served ' <br /> T. ❑ 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 /> I herebycertify that I ha pr ared this application d that work will be done in accordance with San Joaquin County <br /> ordinances,state I ,an r apd reg ula o Of ocal Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT OPER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ` BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> ` PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> rua <br /> OTHER <br /> r� to _7 —`iAS O 1s cA J <br /> ho Received by Date Receipt No, Permit No. Issuance ate Mailed De ivere // <br /> - APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES `� 1601 E.HAZE TON AVE.,P.O.aoa 8009 STOCK N',CA 101 <br />