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i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE / <br /> LIQUID WASTE <br /> Application is hereby made tc carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name(DBA) ,4 SuJ P®a/SrJLe�eno.✓ —Address /Zr i' aerAPLE . S7ae_trr-,✓ <br /> a: Owner Fe_n VD J4 e7 o F-� Address <br /> Firm Partners,Addresses and Telephone Numbers - 4116 <br /> 1 < Business Telephone No. � S-1 9 7/ Emergency Telephone No. <br /> Contractor Licence No. AS 3 SSl3 _ <br /> L Applicants Name (Print) F"YD yJmm-FJ Title arynEe— Date 3-9-8/ <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 - <br /> I Description(Make/Yr.,Color) <br /> Serial No. CAL License No. CAL. Licc:lse 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 /> JobAddress/Location -7/LD A/ ALL JZD L/.I/DE Al <br /> Owner Address S.41a"sE 11 <br /> ❑ SEPTIC TANK ❑ CESSPOOL .k LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT S <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 4REPAIR ❑ OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site y <br /> F. No. of Units Equipment Storage/Cleaning Uocation(s) <br /> 1)4 6. ❑ PACKAGE TREATMENT PLANT Eor 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: ❑ Lass Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq.Ft. <br /> - I] DRY CLEANING,Chemicals Used/Amount/Mo. <br /> r <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 rulel and regulations fort <br /> /S7en Joaquin Local Health District. ✓�fj/ <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Doe'. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 3/ ❑ July 1 8 Received By July 31 I <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED I..�/. AMOUNT <br /> I FEE _ 1 f-.+ .. <br /> f LESS + f <br /> -PRORATION <br /> PLUS <br /> l' PENALTY :( <br /> .OTHER /Jl <br /> OTHER ,� A. <br /> 1 <br /> eceived M Date ' Receipt No. v Permit No Issuance Date MUINd Daawratl - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL NEALTN PERMIT/SERVICES lael E.HAMLTON AVE,P.O.aoa Eeea STOCXTON,CA MWI . <br /> I f r <br />