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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />-'. APPLICATION <br />..._ ..,.."... <br />. <br />(For Non-Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />LIQUID WASTE <br />_ Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District , <br />, Business Name (DBA) 'D. 4 . P.4 ie....e. ) S 1-L4L,SAALS4_ Address Pea Bo st 14za,„Tm4.1_9.C.w./ <br />li Owner Address 4 <br />Firm Partners, Addresses and Telephone Numbers <br />St. Business Telephone No. ___,1L_ke.— fcg, a 7 Emergency Telephone No a <br />d Contractor Licence No, .g S-41 343 <br />J I Applicants Name (Print) ______Fi-o y r:I. I..., 0 OD Title -&,5' ,IL._AL.ntr.._ Date 2-.7-9-7, <br />Please check Applicable Category (14) and Fill in the Required Information , <br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) '•,i <br /> 7-- ! <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br /> <br />Serial No. CAL. License No. ., CAL. Lic;:nse Renewal No. <br />i Capacity Gal., Weights & Measures No. ' <br />Equipment Parking Address <br />. 2. 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 <br />Test Location Test Date/Time <br />2( SANITATION PERMIT <br />Job Address/Location 7 7.___ rA 454' J2..4 fide E A.) C At 0-4-074 e" <br />Owner i•-&-14 13-E S. e OJT?, Is.) Address PP i30K 1;74 , Fie EA/C141 .C4.0 0 I I" <br />SEPTIC TANK 0 CESSPOOL Ar LEACHING FIELD 0 SEEPAGE PIT 0 PACKAGE PLANT <br />Z PERMANENT 0 TEMPORARY 0 NEW - .'REPAIR 0 OTHER <br />5, 0 CHEMICAL TOILETS For July 1. - June 30, 19 <br />Type Construction . Disposal Site <br />No. of Units .Equipment Storage/Cleaning Location(s) <br />6. 0 PACKAGE TREATMENT PLANT For July 1, - June 30. 19 ,....._ <br />Operator Name <br />Plant Location <br /> Where Certified <br /> <br />Plant Capacity No, Units Served <br />T. 1:1 LAUNDRY For July 1,- June 30, 19 <br />SIZE: 0 Less Than 1,000 Sq. Ft. 0 More Than 1.000 Sq. Ft <br />0 DRY CLEANING, Chemicals Usecl/Amount/Mo <br />I hereby certify that I have prepared this application and that the worktiwill be done ih accordance with San Joaquin County <br />ordinances, state laws, arid rules and reg ations of t Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />Fee Is Due: 0 -ANNUALLY. <br />FOR DEPARTMENT USE ONLY <br />0 PER UNIT 0 PER SITE . 0 EACH . 0 January 1 & Received Sy January 31 0 July 1 & Received By July 31 <br />BASE EXPLANATION BILLING <br />DAtE <br />REMITTANCE <br />DATE <br />$ <br />REMI1TED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />4:-. <br />-:71 <br />PLUS <br />PENALTY - <br />OTHER lJ . <br />OTHER • <br />7 .r gkev y 7?-717 0/471 , . Recent by <br />anal If', \ ILIT—CICTI NOM al I <br />te Receipt No. . Peonit No. <br />,r111111.0 Tn. ClIZU111111111.C112,1 Ur Al VIA neekaavreeel......0 <br />issuance I malted <br />46/14 C al.11111,nu nun e n sap., •Indu. c•rne <br />e <br />ned rt6 04.0111