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APPLICATION <br /> For Non-Transferable, Revocable,and Suspend` ) <br /> ENVIRONMENTAL HEALTH PERIIII SEPTAGE <br /> LIQUID WASTE <br /> Applicant is here made to parry n bLy�iness in the jurisdictional area of th San Joaquin Local Health District <br /> F Business Name (DBA) -+_A�—P1�(C/L �g JeNI Address h- L_114 /�/-S� ,�71C.✓ n� <br /> iOwner Address �C\ <br /> Firm Partners, Addresses and Telephone Numbers — [� <br /> ` Business Telephone No. N66- 9607 Emergency Telephone No. <br /> Contractor Licence No. <br /> LAPPlicants Name (Print) 412AUZ/E rAA/D V--f Title ES�- Date ' <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 /> Serial No. CAL. License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights &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 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 a /(liSf_ .4U£ /Y/,Q.rlTFY.AAy <br /> Owner Sr n �1 <br /> oL VyC7— Address S�ftf_- <br /> ❑ SEPTIC TANK ❑ CESSPOOL )0 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IM REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) U <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <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 Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE)(L�@7.41(® 2�/� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT orPEA SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July t S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE rp . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> $3a 1 0 <br /> lahL� Ali <br /> Received by Date Receipt No. Permit No. ussuanix,Dale Mailact elive <br /> APPLICANT—RETVRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCK ON,CA Ifo— <br />