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r.r.w...w„o .. „ ...� ,-, acu ••ncu OYl/l,,,llOY rluNcnr l.viospi tcu. oc a ,v ­V.. ,iic r.P Nui,auvu. <br /> APPLICATION °°- <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTRGE <br /> LIQUID WASTE $° <br /> Applicatio/�is here/�y made to carryon�usiness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) y• A Nrri tf� Tus Address P4 R'2'y �-O' s7a9���f <br /> a <br /> Owner Address <br /> O.Firm Partners, Addresses•and Telephone Numbers <br /> iBusiness Telephone No. � 9 5 D � Emergency Telephone No. <br /> Contractor Licence No. �� 4 <br /> L Applicants Name (Print) f` Title F Z-1 i11 f4 i i71- Date —/ —9 <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites l <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location 7 7 1/ <br /> Owner 2 hF rTca,cl > �;ti S Address r <br /> X SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT I <br /> IC PERMANENT ❑ TEMPORARY kO NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site s <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ 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: ❑ Less Than 1,000 Sq. Ft., ❑ 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 <br /> �rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS < C J <br /> PENALTY <br /> OTHER \ <br /> OTHER <br /> -79 97 1 V 13/79 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />