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Applications Will Be Processed When Submitted Property Completed. Be Sure To Slgn The -ANN..__. <br />OZCib. <br />f APPLICATION �' <br />�s� — <br />(For Non -Transferable, Revocable, and Suspendable) <br />'V <br />ENVIRONMENTAL HEALTH PERMIT �� SEPTAGE <br />AMOUNT DUE <br />LIQUID WASTE <br />CI-iFCKED <br />Application i hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />F Business Name (DBA) <br />y <br />Owner Address <br />AMOUNT <br />Firm Partners, Addresses Telephone <br />and Numbers <br />2 <br />CL a Business Telephone No. -3 �'��O —Emergency Telephone No. <br />1 <br />" Contractor Licence No. _ � 7% 6 — <br />Applicants Name (Print) G Ga Title Date ' ''"8� <br />-N <br />e— <br />_ <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />-- <br />f 17`❑PUMPER VEHICLE PERMIT�REGISTRATION (FOR EACH VEHICLE) <br />For July 1, � June 30, 19 — - 1.144 `%' Disposal Sites <br />Description (Make/Yr., Color) <br />— <br />Serial No, ! _... _ CAL. License No.. CAL. License Renewal No. <br />I Capacity — — Gal., Weights 8 Measures No... — <br />r Equipment Parking Address.. _ <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19_ <br />No. of Vehicles Stored !i' <br />g <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST Q 9 T <br />"�_ <br />R.S. or R.C•E. Name.. _R'S: or-ReG:E-No.-- <br />Test L tion _ . _ �'" Test Date/Time _ <br />�� s , r: <br />— <br />A,K, 0 SANITATION PERMIT, 6 r <br />Jo4 Address/Location �.___.. ✓�%/����'�^ <br />.,�,���� �O <br />Address!>�Q?— <br />w Owner��L� <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD (.SEEPAGE PIT CKAGE PLANT <br />❑ PERMANENT ❑ TEMPORARY L7 NEW GKREPAIR ❑ OTHER <br />,E <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction — _ _ Disposal Site <br />i No. of Units __ Equipment Storage/Cleaning LocXon(s)—.__- <br />6. ❑ PACKAGE TREATMENT PLANT For J.uly%l,.4June.30,,1.9,_ <br />Operator Name — - — t- t — Where Certified — — — <br />Plant Location <br />Units <br />Plant Capacity —_ ._ _ No. <br />Served <br />7. ❑ LAUNDRY For July 1, - June 30, 19. <br />SIZE: ❑ Less Than 1,000 Sq. Fl., -y❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo..'1 z <br />— - — — <br />— --- <br />t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />1 ordinances, state lawsd. rules nd: regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X -- � t �l• — �}— --- -- <br />.. <br />Fee Is Due: ❑ ANN <br />FEE — <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER — <br />OTHER — <br />FOR DEPARTMENT USE I <br />t-1 <br />UALLY`'• ❑ PER UNIT_ PIP SITE „ ❑ EACtACXB <br />H❑ Jan <br />BASE I EXPLANATIUNLv <br />1 & Received ey .January 31 ❑ July 1 & Recei—d By JU y 31 <br />--- — <br />OZCib. <br />— <br />�s� — <br />Hoceived by Date I-ecdDt No. <br />AMOUNT DUE <br />CI-iFCKED <br />RF.MIrTEO <br />1601 E. HAZELTON AVE., P.O. Dox 2009 <br />AMOUNT <br />--- — <br />OZCib. <br />— <br />�s� — <br />Hoceived by Date I-ecdDt No. <br />Permit No. <br />Inuenrc ate Mailed <br />- APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL H§.ALTIJ PERMIT(SEFIV <br />1601 E. HAZELTON AVE., P.O. Dox 2009 <br />CA <br />