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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appilcation. <br />APPLICATION <br />(For Non-Tranalierable, Revocable, and Suspendabie) <br />ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />LIQUID WASTE <br />Application i ereby made carry on business in thju I d "io, nat area of the Sanj,aquiri-Local Health Djstrq,+ <br />Business Name (D_RrA) <br />-A . ..... Address <br />zOwner__— <br />4 Address . ... . ... <br />Firm Partners. Addresses and Telephone Numbers . ..........+ .... . ........ <br />M Rusiness Telephone No. Em#rgency Telephone No,___ <br />4 <br />Contractor Licence No_ <br />LApplicants Name (Print) <br />—Title Date <br />Please check Applicable Catogary (1-7) and Fill in ti eq; <br />. ....... .. <br />he <br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FUR EACH VEHICLE) <br />For July 1, . .............. — June 30, 19 Disposal Sites . . ........... <br />Description (Makei*,, 0010r) — ------ . . ...... . .. ...... .. <br />Serial No. CAL, License No, CAL. LiWznsa Renewal No. <br />Capacity Get, Weights & Measures No, <br />Equipment Parking Address . . . ..... .. .............. W <br />2. 13 PUMPER YARD <br />For July June 30,119 <br />No. of Vehicles Stored <br />No, of Chemical Toilets Stored <br />3. El PERCOLATION TEST <br />R.S. or R.C.E. Name R.S. or R.G.E. No, <br />Test L tion . . ....... Test Date/ Time <br />A. <br />Test <br />PERMrr <br />Job Addres� /Location I- lz,_ <br />0 <br />Address <br />-,,IPT IC TANK 0 CESSPOOL 41V:!'2C2HIN__G FIELD �rSPEPAGE PIT 0 PACKAGE PLANT <br />0 PERMANENT 13 TEMPORARY IVNEW 0 REPAIR 0 OTHER <br />C3 CHEMICAL TOILETS For July 1, June 30, 19 <br />e Construction r.Disposal Site , <br />No, of Units Equipment StorageiCleaning Location(s) <br />6. C3 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. 0 LAUNDRY For July 1, - June 30. 19 ......— <br />SIZE` <br />.....—SlZE` 0 Less Tnan 1,000 Sq, F',, 0 More Than 1.000 Sq. ft <br />DRY CLEANING, Chemicals Useo/Amounti'Mo. — — _-_ - <br />e01 <br />I hereby certify that I have prepared this application and that the work will be done in a$ctt ance with San Joaquin County <br />ordinances, state laws. and rvies and lationg of the an JoIn Local Health District' <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT UA <br />F—Feie 12 —Due: El —ANNUALLY 0 Pen uNiT PER 517F 11 EACH 0 j y & Rdteiveij By jar-�aly 31 13 july I &Rjeaev'ed aq -j'Jy <br />BILLING <br />PASS CXPLANAr" RE4TTA7C9 1 AMOUNT DUE MECKED <br />OATE AFMMI90 <br />AMOUNT <br />,FEE <br />T�--- <br />LESS—_ <br />PPOAAT4ON i <br />PENALTY <br />OTHER <br />OTHER <br />............... <br />7 <br />P.Orl Oil by Permit No "aly Mww Delive,,ed <br />APPLICANT—RETURN ALL CCHnFS TO: ENVIRONMENTAL "EALTH PERMWSEAVICES 16f01. MAZELTON Ave.. 0.0, S*% 20M STOCKTO CA 0"I <br />