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_ ..� ......r,�.�.., .,� Qum IvJfyn-13It:iaNNucanon. — <br /> APPLICATION t <br /> (For hon-Transferable,Revocable, and Suspendable) ; <br /> ENVIRONMENTA HEALTH PERMIT <br /> LIQUID WASTE <br /> } ApplicatIon le hereby made to carry on busi ess in the'urisdictional area of the SaJoaquin L cal Health District <br /> Business Name (DBA) L- Address oa <br /> Owner 1= NA I IN i T H A I L Address ' <br /> Firm Partners,Addresses an elephone Numbersr, <br /> Business Telephone Na. �. Emergency Telephone No. 1 <br /> Contractor Licence No. <br /> E <br /> Applicant <br /> s Name (Print) Title C(& ate <br /> 1 �, p <br /> t Please check Applicable C41a9pry(1-7)and t=ill In the Required Information <, R „ , <br /> 1. 13PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, Juno?30, 19 -Disposal Sites '. <br /> Description(Make/Yr.,Color) -- <br /> Serial No- CAL:License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> k Equipment Parking Address <br /> f 2. ❑ PUMPER YARD <br /> For July 1, June 30, f9 <br /> No. of Vehicles.Stored <br /> No. of Chemical Toilets Stared , <br /> 3. ❑ PERCOLATION TEST p <br /> R.S.or R.0-E. Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. El SANITATION PERMIT - <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL FIELD .0 SEEPAGE PIT EJPACKAGE PLANT <br /> ❑ PERMANENT EI TEMPORANY �EACHING <br /> W AEPAIA ❑ OTHER v <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30,19 <br /> Type Construction Disposal Site <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 <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.i`° ❑ More Than 1,000 Sq,-Ft. ; <br /> 4 <br /> ❑ .. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I I hereby certify aye prepared this application and that the work will be done in accordance with Sari Joaquin County <br /> ordinances,Bt a lawa, rules and r uiation of the an J quin Local Health District. <br /> APPLICANTS SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1&Received By January 31 ❑ July 1&Received By July 31 <br /> k x' BASE `4 EXPLANATION <br /> BILLING a REMITTANCE. s REMIT <br /> E ' DATE _ DATE REMITTED AMOUNT.DUE .CHECKED <br /> AMOUNT <br /> FEE .`"7� 'r/� - �,;_., „Y .,rr �/Y'.r��� L•�.� <br /> LESS } - <br /> PRORATION ? <br /> PLUS w. <br /> PENALTYHca ! <br /> OTHER <br /> OTHER <br /> � z <br /> Received ( t <br /> y t Dale Receipt No Permit Na 1 u rN a IB Mailed Delivered; <br /> APPLICANT RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE P.O.Box 2009 STOCKTO; CA 9520t ' <br /> .z <br />