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Property <br /> APp�i�atrip SWill Be.Processed When Sub�PPdICATION�rc�cM v <br /> ` `and Suspendable) SEPTAGE <br /> (For Non-transferable, Revocable, <br /> ENVIRONMENTAL HEAL" HPER <br /> i <br /> LIQUID WASTE <br /> ict <br /> ° Joa uin LocaLHealth <br /> I made to car 17 bus' ess i <br /> the' 'ctianal area of thexSa�1� <br /> application' ereby Address 1 <br /> aBusiness Name A) i Address <br /> a Owner- a hone No. <br /> Telephone <br /> Firm Partners, Addresses and Telephone Numbers -Eme <br /> Date <br /> 0.a Business Telephone NO. l <br /> j;,: wTltle ►, <br /> Contractor Licence No. �.� <br /> Pant) pn � °lO i� Sw, , <br /> e gpplicarlts Name ( !w i'7 and Fill in'the Required lnformatfon,, -,E C%'k� <br /> Please check APpllcabl'e Category'f '.� <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION ( OpEACH <br /> A Sites <br /> HICLE) <br /> 1. <br /> June 30;19I� <br /> For July;1; CAL.Lice <br /> Il t nse Renewal No. <br /> tion MakelY.r-,Color) <br /> Descrip ( ��'" " .CAL. License No <br /> Serial No.' Gal weights-&Measures NO- <br /> s <br /> Capacity <br /> Equipment Parking Address2. <br /> ❑'PUMPER}YARD, <br /> For Ju1y'1, '' June 30, 19:x. - <br /> No. of Vehicles Stored <br /> L <br /> No. of Chemical Toilets Stored,I R.S.or R.C.E.No. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name II, Test Date/Time <br /> Test L ation �. <br /> p. SANITATION PERMIT; , <br /> Job Address) ocation Address Z <br /> ❑ PACKAGE PLANT <br /> Own ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> 1�'SEPTIC TAN ❑ NEW PAIR <br /> ❑ PERMANENT- ❑ TEMPORARY <br /> 5 ❑ CHEMICAL.TOILETSII For July 1, -Juno 30, 19Disposal Site y -- <br /> x; Type Construction' 1 <br /> (' Equipment"StoragelCleaning Locations) } <br /> I No.of Units - 1, -June 30. 19�- <br /> } ❑ PACKAGE TREATMENT PLANT For July Y � - r Where Certified I' <br /> 6. <br /> Operator Name: - M <br /> a <br /> Plant Location No. Units-Served_ -,- �A <br /> k � t <br /> Plant Capacity <br /> 7, ❑ LAUNDRY-41 or Julyj�1, -June 30, 19 <br /> ❑ Less Than 1,000 Sq- Ft., ❑ More Than 1,000 Sq. Ft- '{ a - - <br /> ❑ DRY GLEANING,Chemicals Used/Amount/Mo._ <br /> e n Ger that i r the perior�n8ttce a;the wprkfa Yhich this permil is issued,I S1131i not employ any p, <br /> Nomeosnrserarttc�enseda9ent'ss'snnaturetartiftastbetol % 9I I - <br /> qq I-cern; `lltat in'the performance of the work tor which this permit is!!sued,l sial' <br /> insuch ma^ncs as!�In{recall a subject to workman's r arnpensat:on taws-otCttirnla.i' <br /> Contraetor'r hir!" cw_sub-contracting sign tune certifies-Lha follawirig: Y• R, 4 y <br /> Ion laws Ealifo 11id.� "�'1,�j <br /> employ persons subject to workllian's campett .�'` <br /> re tired this application and that the work well 6ee'done in accordance with San Joaquin County <br /> I hereby certifythat 1 have.p P <br /> les and regulations of San Joaquip Local.health Dist�ct. <br /> ' ordinances,state laws, an <br /> APPLICANT'S SIGNATUR_1=X 3 - <br /> i <br /> I" FOR DEPARTMENT USE-ONLY ' <br /> ❑ 'January 1_&Received By January 31 ❑ July t Received By_July.31 <br /> PER UNIT. ❑ P_R SITE ❑ EACH+ +1 t REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ w$ CHECKED <br /> REMIT ` # 1 AMOUNT DUE <br /> BILLING l r� , EMITTED ��?" AMOUNT <br /> _ JJ BASE EXPLANATION DATE 1,DRTE <br /> . .. � <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY' 3. i <br /> OTHER <br /> OTHER <br /> !' k Permit No. Issuance Date, .. Mailed Delivered <br /> Received by � Date ; Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTH PERMITlSERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 S70CKTON,CA 95201 <br />