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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The AW]"1111on. �T' <br /> F ' APPLICATION <br /> c ` <br /> ,i . ' <br /> I •3 Ilk <br /> " � (for Non-Transfnbla H vocable,and Suspendable) <br /> 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 <br /> ;v,r Business N me (DBA) Address <br /> iiiowner Armon R fIrygiiAddress fiiOX <br /> 1 <br /> 2 Firm Partners, Address"and Telephone Numbers <br /> I I Business Telephone No. Emergency Telephone No. <br /> 4 Contractor Licence No. II 4rr;fti / �4[t <br /> / L Applicants Name (Print) fj(,(J//Py- Date <br /> Please check Applicable Category (1-7)and Fill In the Reguir"Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Por Jury 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 6 Measures No. <br /> Equipment Parking Address <br /> Z. ❑ 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 IT rTr �4oQfiTest Date/Time <br /> _WaANPER <br /> Job Address/Loc S 1 ' A_ <br /> _ <br /> Owner-#er,!2 7 _ c f i Rk"d e- Address U t <br /> 0 SEPTIC TANK ❑ CESSPOOL �!LEACHING FIELD '�EIPW 0 PACKAGE PLANT - <br /> JR PERMANENT ❑ TEMPORARY M6l NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ype Construction _Disposal Site <br /> I <br /> 'N o of Units _ Equipment Storage/Cleaning LOCabon(s) -S. -❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 L <br /> Operator Name Where Certified <br /> I Plant Location <br /> Plant Capacity.t No.Unit Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 •. . <br /> SIZE: ❑ Leas Than l,000 Sq. Fl., ❑ More Than I AM Sq.Ft. <br /> Cl DRY CLEANING,Chemicals Used/Amount/Mo. -. -- - — -- — -- <br /> I hereby certify that I have prepared this application and that the Work will be Oona in accordance with San Joaquin County <br /> ordinances. state laws, and rules and regulations of <br /> the San Joaquin Local Health District. <br /> APPLICANT'S NATUREX �70��'—�- -- — -- t <br /> �s go <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY 0 PER UNIT 0 J+ER srrE ❑ EACH ❑ January 1 a Received By Jamury 31 ❑ July 1 a Recd.ed By JwY 31 _ <br /> sSuiT <br /> BILUNG REMITTANCE a <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHEOIt AMOUNT <br /> T <br /> FEE <br /> 445 e <br /> y� <br /> LPRd <br /> OORATION /z - <br /> PLUS <br /> PENALTY <br /> OTH M — <br /> OTIIM - _ <br /> � <br /> W. <br /> /n�C /a a � _ b5bae� sl4s�sa <br /> iyceNW�yr. � R¢Ce,pt r,o. Perm�M No M.aed �-0eliveMd <br /> �►<, Ase : /N =14aw L4011NES To, sroc"ON. <br />