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Applications WIII Be Processed When Submitted Properly Completed.Be Sure To Sign The Application... � <br /> APPLICATION ` <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> �� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 1 <br /> m Business Name (DBA) D A PA.A�-o"n", 2 So.VS Address �'o Box /SZSO .ST.�✓ 9-i>a/ i <br /> i Owner Address . . <br /> �.Firm Partners,Addresses and Telephone Numbers .. j <br /> $ Business Telephone No. ll4G- 94197 Emergency Telephone No. <br /> Contractor Licence No. o3•S�i31<3 - i <br /> L Applicants Name (Print) F�O'Y17 L�JO D'D Title EST/.v9.a vn�- Date 9 4 <br /> Please check Applicable Category (1-T)and Fill In the Required Information <br /> 1. ❑ 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. License Renewal No. ♦ _ <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address - - <br /> 2, ❑ PUMPER YARD <br /> For July 1, June 30, 19 _No.of Vehicles Stored <br /> No. of Chemical Toilets Stored _ �v <br /> 3. ❑ PERCOLATION TESTI <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Tests Location -- Test Date/Time ... <br /> 4. .n+ SANITATION PERMIT <br /> Job Address/Location 1;1. D- g AAT✓DT A 1> '-00-Ag Oi4 <br /> Owner F.2laAJ,C RU IZA V/A/A Address <br /> 11i <br /> 91 SEPTIC TANK 13 CESSPOOL J9 LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0 PERMANENT ❑ TEMPORARY ❑ NEW ArREPAIR ❑ OTHER <br /> 5. Cl CHEMICAL TOILETS For July 1,-June 30.19 <br /> Type Construction_- Disposal Site . <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No.Units Served <br /> T. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,0D0 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 rules and regulations of the quip Local Health District. <br /> APPLICANT'S SIGNATURE X L � <br /> FOR DEPARTMENT USE ONLY <br /> Fee III Due:❑ ANNUALLY O PER UNIT OPER SITE 'O EACH CI January 1 A R..I.d 9y January 31 ❑ July 1 a R..'ew By JWy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Ivy ✓ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER id <br /> -7a1 �5a 9/1�1f 14 <br /> ReceNed M Date Receipt No, Permd No. Isswrlde ailed Delivered <br /> {. -e APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICCES 16e�A=EEL?ON AVE-;P-O-BM 1009 TOCKT.ON•CA aa201 <br />