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Applications Will Be 'cessed When Submitted Properly Completed. Be e-ire To Sign The Application. I <br /> APPLICATION 1400 ` <br /> T (For Non-Transferable, Revocable, and Suspendable) ...Q <br /> l ' ENVIRONMENTAL HEALTH PERMIT SEPTAGE I <br /> LIQUID WASTE —A <br /> Applicatio�pJj''s hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name IDEA) -AMA? XP 919r/.1/Fi C°'O. Address_�.�5 <br /> i Owner !�/fJQ/l /TTf Address i sU. i/V�GG� /}i/ /`�•4NTtCA <br /> 4 <br /> 7 Firm Partners, Addresses and Telephone Numbers y�Z..3-rS72,' <br /> aBusiness Telephone No. --d 23— �-�Z' Emergency Telephone No. 8�•�' 'S Z <br /> Contractor Licence No. /.pia <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) lJ� <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 i <br /> For July 1, June 30, 19 U+ <br /> No. of Vehicles Stored it <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name.. R.S.or C.E. No. / <br /> '�,Ai Location Test Date/Tim <br /> ❑SANITATION PERMIT F ) <br /> ob Atldr s/Location ` �/� C ` <br /> O ner 6 N A SIE ..S'e C' aE"l'i S�� e��it' <br /> a , <br /> SEPTIC TANK ❑ CESSPOOL _ CHING FVEtD ❑ SEEPAGE P PAC A PLANT <br /> PERMANENT ❑ TEMPORARY - MREPAIR 1 <br /> //6. ❑ CHEMICAL TOILETS For July i, -June 0, 19 1 r <br /> Type Construe on P LTlsposal Site <br /> No. of Units 1^S--MYb-t'C Equip "I nt Storage/Cleaning Location(sy <br /> 6. ❑ PACKAGE TREATMENT PLANT For JlyY 1,-June 30, 19 <br /> Operator Name 7 .WhereL%rtified-\ <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 law r es and r la he San Joaquin Local Health District. <br /> APPLICANT'S SIGNA E ,� ly ;C h -/J.4/I�TFC/1 �«1/%d-IAle it O <br /> / l <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> Plus C <br /> PENALTY <br /> OTHER Y ' <br /> OTHER <br /> �SZ.p <br /> to% V-79 1333 -7 -a57_- 0oL7 <br /> Received by Darn Receipt No. Perrut Na. Issuance Date --marled Delivered <br />