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Applications Will Be Processed When Submitted Proper; Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL.HEALTH PERMIT SEPTAGE <br />31Q010 WASTE <br />Application is hereby made to -carry on business in thejurisdictional area of the San Joaquin Local Health District <br />sinesName {DBA) <br />Address, ZA' Ali <br />I Owner—_,--_,_,. Address <br />LI Firm Partners. Addresses and Telephone Numbers <br />. ...... . ... <br />Business Telephone No, Emergency Telephone No... <br />Contractor Licence No. <br />Applicants Name (Print) <br />j__ ,D.2> <br />Title sr- -7-ib Gate Z­­..� <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July June 30, 19 — Disposal Sites <br />Description (Make/Yr., Color) . .. . . . . .. ........ <br />Serial No. CAL, License No. <br />CAL. License Renewal No. <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address . .. . ........ . .. . ...... <br />2. OPUMPER YARD ...... .. . �.­­. <br />For July I- , . June 30, 19 <br />No of Vehicles Stored <br />No of Chemical Toilets Stored,--, <br />.. . . ............... ..... . . .... <br />3. 0 PERCOLATION TEST <br />R.S. or R.C.E. Name <br />. ..... R.S. or R.C.E. No. <br />Test Location Test DateiTime <br />4. & SANITATION PERMIT <br />Job AddressiLocation <br />— _. - -­­-­ - <br />Owner <br />0 SEPTIC TANK 0 CESSPOOL LEACHING FIELD Ok SEEPAGE PIT 0 PACKAGE PLANT <br />2C PERMANENT 0 TEMPORARY NEW 0 REPAIR 0 OTHER <br />5, ❑ CHEMICAL TOILETS For July 1. - June 3o, ig <br />Construction Disposal Site <br />of Units . . .. . . . . . ........ .... Equipment Storage/Cleaning Location(s) <br />6, 13 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 . ..... <br />Operator Name Where Certified ............... <br />Plant Location ­--­ - . . . ....... ­­­ Nii �1 <br />Plant Capacity ­­­ � I <br />No. Units Served <br />T. 0 LAUNDRY For July 1, - June 30. 19 <br />SIZE. 0 Less Than 1,000 Sq. Ft,, E3 More Than 1,000 Sq, Ft - <br />0 DRY CLEANING, Chemicals Used/Amount/Mo. . .. . ........ .. ... . . ................. .. <br />I hereby certify that I have prepared this application and that the work will be done in accordance v4th San Joaquin County <br />ordinances, state laws, and rules and regulations cif-lbe San Joaquin Local Health District <br />APPLICANT'S SIGNATURE X z <br />. ... ...... .. . ........ . <br />FOR DEPARTMENT USE ONLY <br />F'Fae IS 0": AINNkJALLY [] PER UNIT 0 PER SITE EACH jarwary I & A 6i4ow, By January 31 July I Received By �,u:y Ai <br />'�I.AL <br />sc <br />RAW EXPLANATiONAMOUNT DUE CHECAIFO <br />BILLING F41EM TTANCR <br />DATE DATE i REMITTFO <br />- ----- AMOUNT <br />FF -E <br />q <br />PROP ATION <br />OTHER <br />OTHMI <br />in's <br />ed - b . y <br />n�: <br />Pormil tsia Man" 0310 A �Aed diiive�ri <br />L OCANT-.1111TUAN ALL COMES TO: ENVIII404WIRNTAL HEALTH PERWT,1sC"C85 1801 1. HAMELTON Avg., P.O. Box aM STOcXTON' CA 1=11 <br />