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ri Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> i ENVIRONMENTAL HEALTH PERMIT SEPTAGE Q <br /> X7_7_-�~..._M tLG �o A U� . <br /> LIQUID WASTE 2-GO- o�2.S <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) � X)A-ZS t�n✓I/ 7� �aN Address pO <br /> aOwner 4 0 p �� 1-7hme 1 Address t <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> 4 Business Telephone No. _0�3- `rte/! Emergency Telephone Na. <br /> -J Contractor Licence No. SS--G <br /> a ate <br /> L Applicants Name (Print) 19an7hoeypTitle [`ac9fYTa+.}'CrAY Date <br /> Please check Applicable Category(1-7)and Fill in 1h Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) . <br /> For July 1, June 30, 19 Disposal Sites 3 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic.ase 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 j <br /> a <br /> No, of Chemical Toilets Stored ' <br /> 1.. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> TBst Location Test Date/Time w <br /> 4. ® SANITATION PERMIT <br /> Job Address/Location Cp25JPeX Y e T Y,44 <br /> Owner &--*W' f' —W-1AK Address <br /> SEPTIC TANK ❑ CESSPOOL 'LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site t <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified t <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq- Ft., ❑ More Than 1,000 Sq. Ft. p' <br /> ❑ 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 with San Joaquin County <br /> ordinances, state laws, and rule nd regulations of the San Joaquin Local Health District. I <br /> APPLICANT'S SIGNATURE X a <br /> ,w FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT LO,PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - ^� <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT EE <br /> �J (�"� L� 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> • ,may, ) �A - <br /> ` <br /> Received by f Date Receipt No Permit No Issuance Date' Mailed ed <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STON� ,; <br />