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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION \\ <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatiogg�is L,er�p y madey�to Carry on VIM the jurisdictional area of th San Joaquin Local Health District G �` <br /> mess Name(DBA) /`1 �. /J,4MYT�CN� ye _Address O. C7ul; / U 8 *o;+Ivy 104/ (`p <br /> ner SA/—1 4 Address <br /> 2 Firm Partners, Addresses and Telephone Nuers —' <br /> IN. Business Telephone No. 7/05/- mb/G <br /> Emergency Telephone No. <br /> j Contractor Licence No. //43,70 <br /> L Applicants Name (Print) A l Ae .eAn nu Z7rIN / <br /> Please check Title O_ W /E 21 Date _/.� - n�. <br /> Applicable Category(1.7)and Fill in the Required Information p� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) o <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 1Location Test Date/Time <br /> 4. q SANITATION PERMIT <br /> Job Address/Locati n_ �7'`�'�L� //�,['uJ &,>,z ��, <br /> Owner f� L .VA4, ' LC-��'Rr Address T O. &djv / <br /> SEPTIC TANK ❑ CESSPOOL W LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> T Construction Disposal Site 9 t <br /> f Units Equipment Storage/Cleaning Location($) .J <br /> 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 1,0D0 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals USed/Amount/MO. <br /> I hereby certify that I have prepared this application and t the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, rulgs_a regulations of the J Squirt Local Health District. <br /> APPLICANT'S SIGNATURE X C,LfJ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t a Receiver!By Janua <br /> ry 31 ❑July 1 8 Rxeiued By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUN7 OUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEELESS <br /> p��Oa <br /> P ORATION 7 <br /> PLUS <br /> PENALTY <br /> OTHER D <br /> OTHER <br /> Raetivee by D ale, c.7 b 8✓ ( / �� <br /> Receipt N0. Permit No. Iaauenee Gate aila0 beliveree NN"�� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 16101 E.HAMILTON AV ,900 ams $TOCKTON.CA 95201 <br />