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R Applications Will Be Piocaaaed When SubrNtlad Property Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> (For Non-Tranaterable. Revocable,and Suspendable) SEPTAGE , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> UQUIY W"TE <br /> AOpl kation is hereby made to carry on business in the jurisdictional area of tf��,n L�y n Local Health DiCI�� — — <br /> Business Name (DBA) 7 A Perm >f se.rf f Address <br /> Address <br /> Owner 1 <br /> Firm partners, Addresses and Telephone Numbers _ Emergency Telephone No. <br /> Business Telephone No. 416 A- !6607 _ — <br /> Contractor Licence NO. <br /> )I � - — Title <br /> Applicants Name (Print) g�1IIf1 � — - PST DN° <br /> 0 <br /> pleaaa cheek Applfeable Category(1.7)and Fill M 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) -- - .LlOall/e Rallallilat NO. I <br /> Serial No _-_ — —_ _ CAL. License No. —_ <br /> Capacity _ — Gal.,Weights&Measures No.— 1 <br /> Equipment Parking Address — <br /> 2. ❑ PUMPER YARD I <br /> For July 1. June 30, 19 t <br /> No.of Vehicles Stored — -- <br /> No. of Chemical Toilets Stored --- <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E.NO. <br /> RS. or R C.E.Name _ —- <br /> _ Test Date/Time <br /> Teat Location — --- — <br /> a. ® SANITATION PERMIT <br /> Job Address/Location _j.96Sy U SA�Ir E 11 <br /> Owner nL6A--- -s <<�A '� — Address <br /> ❑ SEPTIC TANK 0 CESSPOOL <br /> LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT 6 <br /> (] OTHER <br /> ❑ PERMANENT ❑ TEMPORARY 0 NEW M REPAIR <br /> ❑ CHEMICAL TOILETS For July 1, -June 30. 19 <br /> .,,a ConstructionDisposal Site <br /> No of Units <br /> Equipment Storage/Cleaning Location(s) <br /> 6. O PACKAGE TREATMENT PLANT For Juty J. -June 30, 19 . _VV11ero Certified <br /> Operator Name <br /> Plant Location _ - <br /> Plant Capacity No. Unita Served _ <br /> 7. ❑ LAUNDRY For July 1,-June 30. 19 <br /> SIZE C3 LESS Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. — - — --� <br /> 1 hereby tartly that I have prepared this application and that the work will be done in accordance with San Joaqui County i <br /> ordinances.state laws <br /> \and <br /> rules and regulations of the San Joaquin Local Health District r <br /> APPLICANTS SIGNATURE X' ��'�---"� — <br /> FOR DEPARTMENT USE ONLY <br /> Fee N Due: 0 ANNUALLY ❑ GER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Raiu,W E BY January 31 ❑ JuIY 1 8 Recciva0EM1T By VH 31 <br /> 1 e1WNG REYrrTANCE s AMOUNT WE CHECKED <br /> BASE EXPLAIMTION DATE REMITTED AMOUNT <br /> IA 1 <br /> TEE <br /> ill} •� <br /> t <br /> I PRORATION r <br /> PFr \ _ <br /> OTHER <br /> OTHER _ <br /> M <br /> �r n..V1lea once IAaXad D <br /> L AFeLlCARf—I�TUIeaALL pORtaa TQ { ENVIROIW®iTAI HEALTH PERMIT/SERVICES teal E.HA2ELTON AVE.RA.am 2M STtOCkKTOKTON. ` <br />