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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ T <br /> APPLICATION <br /> f ' (For Non-Transferable, Revocable,and Suspendable) <br /> 4 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 f <br /> N Business Name (DBA) s IC �7p� rK�,y� _Address 20 f`7 AGII P ,57' 1�4 <br /> aOwner �+.5 AC.r� CA <br /> . Z� Address A �= S �AIALE <br /> ,Firm Partners, Addresses and Telephone Numbers <br /> 7 <br /> a Business Telephone No. � ` S Z1 Emergency Telephone No. - -7 �;4 <br /> Contractor Licence No. <br /> L Applicants Name (Prins V c Title <br /> Date <br /> Please check Appiicatrle Calegory (1-7) and Fill in the Required Information � <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July',, BeJu30; 19ti4 , <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL" Liccnse Renewal No, <br /> Capacity Gal., Weights & Measures No. 3 <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARDFor July 1, June 30, 19 <br /> No. of Vehicles Stored, - r <br /> No. of Chemical Toilets Stored <br /> r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _,"° <br /> -R:S. or R:C.E:No. <br /> Test Location Test bate/Time <br /> 4. 9 SANITATION PERMIT ,`�` <br /> Address/LocationJob ZZ -- Is <br /> Owner <br /> � Fc� t4 �Aco1-f � : <br /> t Address 2223 <br /> )I SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment-Storage/CleaningLocation(s) <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> I <br /> Aerator Name ,Where Certified <br /> Plant Location- <br /> Plant <br /> ocationPlant Capacity �No. Units Served r <br /> 7. ❑ LAUNDRY For—July-17, -June 30, 19- e— � t i ; 4 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft" <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> fie <br /> = o 277 SJ!'NTA PLITA AVia. <br /> M I hereby certify that l have pr ared this application and that the work a ne in acc�r �Hii �( 1 ,kggg0ounty <br /> ordinances, state laws, and les nd r lations of the San Joaquin or ie in ac`. LIC. �,�� <br /> (_09) 677-8622 <br /> APPLICANT'S SIGNATURE - + <br /> F6h_DEPART4ENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Reserved By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE g REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION 3 <br /> PLUS <br /> PENALTY <br /> A <br /> OTHER <br /> OTHER <br /> Received b ` D <br /> Y Date Receipt No. Permit No. Is ante Date Mailed — e rve d _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.WAZELTON AYE.,P.O.Box 2009 STOC TON,CA 95201 <br />