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Applications Will Be Processed When Submitted Properly Completed. Be sure I o ugn u, <br />ier <br />APPLICATION <br />(For Non-Transterable, Revocable, and Suspendable) <br />E NVIRONMENTAL <br />SE PTAGE <br />-s <br /> HEALTH PERMIT e <br />,,•-• UQU1D WASTE <br />ApPlicatio is hereby made to car on business In the4unsdictional area of the San Joaquin Local Health Dis;; <br />et. . <br />Business Name (0 ) ^ • i - _..e-e-a-__ Address._ _1_2.arZfee '7Z 7 <br />r <br />'i Owner_. _ ,4•-"Aoss.L.--__. 4,e-cl-R--- — Address <br />Firm Partners, Addresses and TelePhone Numbers _ — <br /> — -- — <br />ausiness Telephone No 36..fr .5-/e, :5— — Emergency Telephone No. —.... <br />Contractor Licence No._ <br /> <br />L <br />Date <br />a <br />Title —RCA-4-d <br />i Applicants Name (Print) ___ ___: _ OL __-) <br />Please check Applicable Category (1-7) and VIII In the Required Information I <br />1. 0 PUMPER VEHICLE PeRiAri REGISTRATION (FOR EACH VEHICLE) <br /> <br />For July 1,_ _ _June 30, 19 -II _ Disposal Sites -- <br />Description (Make/Yr., Color) <br /> <br />CAL. License No, CAL. License Renewal No.__ 4. • <br />II <br />Ja <br />• <br />SEPTIC TANK 0 CESSPOOL <br />LL <br />July 1 8 Received By stuty 31 <br />Fee Is Due: 0 <br />REMITTED <br />_ <br />FEE <br />LESS PRONATION <br />PLUS <br />PENALTY <br />OTHER <br />VSertal - •••••••• <br />Capacity " Gal.. Weights & Measures No <br />Equipment Parking Address <br />0 PUMPER YARD <br />For July 1_ ___ June 30, 19 <br />No. of Vehicles Stored <br />No of Chemical Toilets Stored <br />0 PERCOLATION TEST <br />R.S. or R.C.E. Name I <br />Test L9cation <br />Ni SANITATION PERMIT <br />JulD Address/Location /2 A <br />Owner <br />PERMANENT 0 TEMPORARY 0 NEW 0•REPA1Ft - __a0 OTHER <br />0 CHEMICAL TOILETS For July 1,- June 30, 19 —_ <br />Type Construction _ ___II_ Disposal Site <br />_ _ _ _ <br />No. Of Units ________-_---,1- _ Equipment Storage/Cleaning Location(S) _ <br />0 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name -- II .. — _ _ Where Certified — <br />Plant Location — 9 • . <br />..,4, <br />- --- - •- <br />Plant Capacity 9 . _ No. Units Served <br /> <br />«- <br />7. 0 LAUNDRY For July 1, -; June 30. 19 <br />SIZE, 0 Less Than 1,000 Sc. Ft., 0 More Than 1,000 Sq. 'Ft <br />0 DRY CLEANING, Chemicals Used/Amount/Mo. _ <br />I <br />I <br />III hereby certify that I have prepared this application arid that the work will be done in accordance with San Joaquin County <br />ordinances, state laWs, and rule and regulations t the San Joaquin Local Health District. <br />'I APPLICANT'S SIGNATURE X — <br />\ 71° FOR DEPARTMENT USE ONLY <br />I.NNUALLY1 0 PER UNIT 0 PER SITE 0 EACH 0 Janda 8 Pet •ed By Jaouary 31 <br />II <br />SAL EXPLANATION BILLING REMITTANCE <br />DATE DATE <br /> I <br />, , <br />R.S.-or R.C.E. No.. / <br />i Test Date/Time — , i <br />I Su . . .i. <br />"1.1-1A--r_ 1/2,4_ ____52..., c...* ,52 .z.-4, <br /> Addre'ss <br />&- <br />LEACHING FIELD SEEPAGE PIT .0 PACKAGE PLANT .-..• <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />01-HER it <br />Received by Date <br /> APPLICANT-RETURN ALL COPIES TO: <br />II <br />ify_ps5 <br /> Receipt Permit 'No. <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> <br />-3 O <br /> <br />c Date Mailed 15iiiáred <br />ELTON VE., .0. Box 2009 ST KTON. 93201 ./A <br />3 7 8'., .1 <br />••••••••••••••••••••00.11•••••••,,