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Applications Will Be Processed When Submitted Properly Completes tiesure Io algn 1"t! <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) J <br /> � , ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 0 <br /> Application i hire made C on b1 s' lessinthe jurisdictional area of the n` a in Loc Heal ,Qistrict � L <br /> aBusiness Name B ) - L Addr ss J f e, r I�} s1 <br /> Owner Address e� �p <br /> J Firm Partners, Addresses and Telepho m ers O y7� S6� <br /> aBusiness Telephone No. � Emergency Telephone No. g <br /> Contractor Licence No. C4/2Z ?-7 -- <br /> Applicants Name (Print) o Title Date <br /> I Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1, 0 PUMPER VEHICLE PF_8MIT REGISTRATION FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) - — - - <br /> r Serial No. ' -T"` CAL License o. 017N CAL, Liccnse Renewal No. <br /> e+y -•. <br /> Capacity _ Gal., Weights & Measures No. �.. <br /> w .. <br /> Equipment Parking Addr se s _ a <br /> 2. ❑ PUMPER YARD x>` <br /> For July 1, we_ June 30, 19 <br /> No. of Vehicles Stored M <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Le <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> � . <br /> Testi Location r__ ''r TestDate/Time r <br /> 4. ❑ SANITATION PERMIT* L i <br /> Job Address/Location > 'nC <br /> r <br /> Ownerin,4na-e_L n4t V <br /> '"I Address i <br /> SEPTIC TANK ❑•CESSPOOL,..,..., LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENTS "'❑'TEMPORARY NEW ❑ REPAiF:- -vOTHER <br /> 5.-E] CHEMICAL TOILETS-For July•1,=June 30; 19 <br /> Dis osal Site <br /> Type Construction P <br /> No'.of Units Equipment Storage/Cleaning Location(s) <br /> 6#`11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Y f <br /> t <br /> Operator Name Cf Where Certified <br /> -. <br /> Plant Location <br /> Plant Capacity No. Ur its'Serve <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.r. "-7 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j .00: �. <br /> r I hereby certify tat " have prepared this application.and that the work will besdone Ingaccordance with'San Joaquin County ` <br /> ordinances, state laws,Fan a regulations of _"San JoaqW Loc I Health D tricto""-s "' "'llw- <br /> 1 APPLICANT'S SIGNAT R /—y 1 -41 <br /> c ► /S r +.fir- ar+�.r. y.� <br /> 0'r <br /> ' j .�.• jor <br /> FOR T U ONLY <br /> .r / �» <br /> R SITE H, '❑ Janus 1 8 Received By January 31 July 1 &Recei 6y July 31 <br /> Fee Is DUeC ❑ ANNUALY ❑ PER UNIT ❑ PE 5 rY <br /> � ^+ REMkT <br /> BILLING REMITTANCE . $ -- <br /> 1 BASE,- EXPLANATION AMOUNT DUE CHECKED <br /> I S DATE DATE REMITTED ' i AMOUNT <br /> FEE <br /> I LESS �-• <br /> . PRORATION d �* <br /> PLUS all <br /> I PENALTY +? <br /> OTHER r <br /> 1 <br /> I OTHER <br /> Received by' /. 'bate 0, Receipt No. Permit No. I ance to Mailed :- Delivered <br /> AVE.,P.D.BoM 2 ST CKTON,CA 45201 <br /> APPLICANT—RETURN ALL COPITO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON <br /> ES <br />