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Applications Will Be Processed When Submitted Properly Completed, Be Sure To SignThe Apt.-_:�w�; <br />F APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) <br />SEPTAGE <br />Cliver , <br />r ENVIRONMENTAL HEALTH PERMIT <br />ENVIRONMENTAL <br />h LIQUID WASTE <br />1601 E. HAYELTON AVE., P.O. Box 2009 <br />r .--....—..__� <br />_.- <br />C Application i hereby made to carryon business In the jurisdictional area of the San Joaquin Local Health District <br />F Business Name (D .6LZ-- Add re <br />I <br />aOwner _ — Address <br />V Firm Partners, Addresses and Telephone Numbers --- ----- - _ <br />--- •Q <br />0. Business Telephone No. O v - Emergency Telephone No. <br />J Contractor Licence No. <br />Applicants Name (Print -Title Date'_ <br />) <br />—fN` <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />f 1y ❑ PUMPER VE4 ICL_E PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, . June 30, 19 _ 3 1 N' Disposal Sites—, <br />----- <br />Description (Make/Yr., Color)— <br />Serial No. _—. _ _. _ CAL. License No. CAL. License Renewal No., — <br />1 Capacity — — Gal., Weights S Measures No.. — - <br />Equipment Parking Address --- -- -- <br />t 2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />C No. of Vehicles Stored <br />No. of Chemical Toilets Stored --- <br />3. ❑ PERCOLATION TEST 0— <br />Z <br />R.S. or R.C.E. Name. �_. i?_R:S or-R:C:E-No.,- <br />Test,L�tion _ ^'"" Test Date/Time — —. <br />4. l!J SANITATION PERMf <br />— <br />' <br />Job Address/Locati�on/�� �— ��6�—L - -•— <br />_ . - <br />w Owner -�A Z_ Address •:(Q?- %fid!— l�>✓���1�' <br />c <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD CA -SEEPAGE PIT CKAGE PLANT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br />X <br />5. ❑CHEMICAL TOILETS For July 1, - .lune 30, 19 <br />7 <br />Type Construction — _ _ Disposal Site <br />i No. of Units _. Equipment Storage/Cleaning Location(s) —. -- — <br />6. ❑ PACKAGE TREATMENT PLANT For <br />—_.— J`UIy"�1;,:JuneT.30..1.9•_ <br />Oporator Name _ T v_ Wee Certified — <br />---- -- — <br />.- <br />PlantLocation— <br />Plant Capacity—'.__— —. — — No. Units Served— <br />! 7. ❑ LAUNDRY For July 1, - June 30, 19. <br />SIZE: ❑ Less Than 1,000 Sq. Ft., 'y❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. 3 -- - — — — — — <br />. <br />j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />t ordinances, state laws _a! d_rules nd regulations of the San Joaquin Local Health District. <br />n 4 <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE <br />Fee Is Due: EJ ANNUALLY;`• ❑ PER UNIT PER SITE ,- E3 EACH [:I is <br />•^BASEI EXPLANATION`' �1'RIItING ' REMIT t <br />.. ---- -- - —' � --- 0A7E -- - ATI - <br />F <br />FEE i <br />LESS <br />PHORATION J <br />PLUS— <br />PENALTY <br />OTNER <br />OTHER -- <br />Received by Date <br />— APPLICANT—RETURN ALL COPIES TO: <br />a & Received Ry .lanvary 31 ❑ <br />$ . AMOUNT 011E <br />nFMi rTED <br />G�� <br />I & Reeelved By Ju y 31 <br />REMI r <br />CHFCKED <br />AMOUNT <br />HecCipt No. <br />Patrn rt No. <br />Issuance ate Mailed <br />Cliver , <br />ENVIRONMENTAL <br />HgjALTV PERMIT/SERV <br />_ �__ _er <br />1601 E. HAYELTON AVE., P.O. Box 2009 <br />r .--....—..__� <br />_.- <br />STOCK/ ON, CA 5201 --- <br />-.-I- <br />