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' �ppllcatlonsWil1 Be Processed When Submitted Property Completed,Be Sure To Sign The Application. <br /> r K APPL'ICA'TION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> APPIicaP n is-he aby nada to c r LIQUID WASTE <br /> w Business Name OBA ;;yy on bus' as in h Jurisdictional area of th_ <br /> ( ) r�-� }•1 I `QAC S( s n oaquin Local Health D'strict. <br /> a Owner I �.F „i A l ddress , <br /> '12 Firm Partners, Addresses an Telephone Numbers Address - <br /> a Business Telephone No. <br /> 'I Contractor Licence. - Emergency Telephone No; . <br /> LApplicants Name{t?rin() .�• ;.E„'E \A( A�"�,)np i( �-_� - <br /> Please check Applicable Cate o —'�—'Title. <br /> 1 Y .� pry(7-7)and.Fill in the Required Information - _•ate <br /> jj M7MPEli�VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> ' For July Y. _; ,."-'• <br /> June 30119 - Disposal Sites <br /> Description(Make/Yr.,Color) • " - "` _ <br /> Serial No. <br /> cap,! t•T^'-^— CAL. Llcense.Nb. . <br /> TM'--Ga1.7 Weights$Measures`No`--�- w..__/_,_',' CA'C-License Renewal No- <br /> Equipment Parking Address ^-�' ---•(- - <br /> 2- ❑ PUMPER YARD- � �� '• <br /> For July 1, June 30, 19 T <br /> N_o. gf_Vehicles_Stored <br /> No.of Chemical Toilets Stored <br /> 3• ❑ PERCOLATION TEST 'T --- <br /> R.S.or R.C.E. Name Y �' <br /> 'Test Location ) i R.S.or R.C.E.No, <br /> 4- 0 SANITATION PERMT Test Date/Time .� <br /> Job Addre location <br /> ���SEPTIC TANK ❑ CESSPOOL Atldress <br /> ffr[[[���"' EAGMNG FIELD SEEPAGE PIT ❑ PACKAGE PLANT. <br /> PERMANENT ❑ TEMPORARY NEW - <br /> ❑.CHEMICAL TOILETS�Fcr Jul 1,- °•-� EPAIR ❑ OTHER <br /> Y Jun 30, 19a Y <br /> ype Cdnetruction I ' 4 <br /> of Disposal-Site <br /> o. Units I Equipmmeni Storage/Cleaning Location(s) ^ <br /> l PACKAGE TREATMENT PLANT For Jul 7,- - <br /> r❑ <br /> y JUne 30, 19 - <br /> peator Name - - <br /> nI Location where Certified <br /> �(a <br /> giant Capacity '� - <br /> ❑ LAUNDRY No. Units Se ved <br /> , For July 1,-June 30, 19 i r <br /> ZE: 13 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft <br /> ki-DRY <br /> CLEANING,Chemicals Used/Amount/Mo. I. <br /> • « I hereby car et I Have prepared his'application nd ihat the work'wlll be done in accordance with San Joaquin County <br /> ordinances,state law Ind cut s end an Joaquin Local;Health District. .I <br /> !1 •.1w. _ l a f 1 <br /> PPLICANT'S SIGNATUR <br /> - FOR DEPARTMENT USEONLY <br /> YY II *T! <br /> ( ! <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE !EACH ❑ Ja�w 1&Recelvea a Janue AI. 1 r 1 <br /> ' Y' ry• ❑ July 1&Received BY Juli"3J 1 <br /> }a1LLING� gEMITTAN'CE REMIT I <br /> i. BASE EXPLgNATION DATE S _ <br /> fir'• DATE ( 1 REMITTED AMOUNT DUE CHECKED..: <br /> AMOUNT <br /> FEE <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY h �! �y .�• , <br /> ' OTHER .. r <br /> a OTHER / I <br /> 7a edZ <br /> -by�e� <br /> Date <br /> Ree R pt No y Per it No I Y Y luuance Det a Mailed pel,vered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/S RVILEs • 1901 E.HAZELTON AVE.,P.O.90 00w•V�e'rQ�^ION,CA 9a. <br /> V1� 11`1 ! G <br />