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V V <br />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 />Application is hereby made to car on business in e jurisdictional area of the0. Srm Joaquin Local He=ict <br />1 Business Name (SBA) Address <br />z Owner • "-./..'Amy /41..E.—, Address <br />a <br />(2.,. Firm Partners, Addresses and Telephone Nu bers <br />t. Business Telephone No. 3/0" Emergency Telephone No. <br />4 <br />Contractor Licence No. <br />Applicants Name (Print) .413,—.13 Alf01‘1-9e- Title Date 9-2 11-1/ <br />Please check Applicable Category (1-7) and Fill in the Required information <br />0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. CAL. License No. CAL. Liccnse Renewal No. <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 /> <br />No. of Chemical Toilets Stored <br />3, 0 PERCOLATION TEST <br />R.S. or R.C.E. Name <br /> <br />R.S. or R.C.E. No. <br /> <br />e 0 Job Address/Location <br />Owner . ARM, <br />SEPTIC TANK <br />PERMANENT <br />0 CHEMICAL TOILETS <br />jpe Construction Disposal Site <br />No. of Units Equipment Storage/Cleaning Location(s) G\ <br />6. 0 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: 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br />DRY CLEANING, Chemicals Used/Amount/Mo. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rul rid regulations of the San Joaquin Local Health District. <br />caS <br />Testeation Test Date/Time <br />4. SANITATION PERMIT <br />CESSPOOL <br />TEMPORARY <br />For July <br />Addressj_43 __5t2_, keeciel c)1 <br />1:3 LEACHING FIELD -J,EPAGE PIT 0 PACKAGE PLANT ') <br />NEW R.—REPAIR 0 OTHER <br />1, - June 30, 19 _ <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 By January 31 0 July 1 & Received By July 31 <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />S <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE A I--I 5 3 145 <br />LESS PRORATION <br />PLUS PENALTY <br />OTHER <br />OTHER <br />i333 9 ,X3 12 I <br />--------------------------... Received by Date Receipt No. Permit No 6iJancelDate Mailed Delivered <br />..-.. -.. ---...........---- .... e caa,e. ,eue AUc n a 13.... MA& ern,,,,, ,A OS9111 <br />APPLICANT— .