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Applications Will Be Processed When Submitted Properly Completed. Be S&Io,.Sign The Application. t-- <br /> APPLICATION SEP 2 8 1979 <br /> (Far Non-Transferable,Revocable, and-tuspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQIUIN L� AGS � , <br /> LIQUID WASTE HEALTH DISTRICT <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 4+ <br /> NBusiness N/a�me (DBA) ® �lr Address 40 C y <br /> a Owner �Ax Y is / • AddressL �F TL' — <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. (41 - <br /> RO? —�r r ' �' 9 Emergency Telephone No. <br /> Contractor Licence No. <br />'T Q Applicants Name (Print) Title Date 8 0 <br /> L <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> (31 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites IAI <br /> Description(Make/Yr., Color) { <br /> Serial No. CAL. License No. CAL. License Renewal No. 3 <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ` <br /> E No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST } <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time d <br /> 4. X SANITATION PERMIT <br /> Job Address/Location <br /> Owner ME Address <br /> SEPTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY J�NE W '- ❑`REPAIR ❑ OTHER-. $► _ <br />{ 5. ❑ CH EMI CALTOILETS For July 1, -June 30, 19 <br /> 9 <br />�. Type Construction <br /> 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 /> n <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r � - <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 rules and regulations of the San Joaquin Local Health District. <br /> a � <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 41- <br /> LESS <br /> PRORATION <br /> PLUS <br /> F PENALTY <br /> OTHER <br /> OTHER <br /> CD OS <br /> c) 3 •7 <br /> Received by ec <br /> Date Reipt No- Permit No. Issuance Date Mailed eliver d <br /> ,I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,C 95 1 _ r <br />