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Applications Will Be Processed When Submitted Properlycompietea. <br /> } APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEP7AGE <br /> " ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE. <br /> Application is hereby ma a to carry on usiness in the ju dictional area of the Sa ;agyi n Local Health trict <br /> Business Nam (DBA) - Address <br /> a Owner <br /> Address G { <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> Z <br /> Contractor Licence No. Date �r <br /> L Applicants Name(Print) - � s r : Title <br /> Please check Applicable+Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June'30, 19 - Disposal Sites t <br /> Description(Make/Yr., Color) CAL. ccnse Renewal No. <br /> Serial No. CAL. License No. <br /> ` - <br /> ^ N <br /> Capacity Gal., Weights,&�M.easures No. t <br /> Equipment Parking Address i 6 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,`19 4 1 <br /> I No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST <br /> 1 R.S. or R.C.E. Namek---^--- 1 t.- or,R.0 E 4% <br /> �('',.t'!'rt.ihi,,li .i� <br /> Test Location Test gate/,Tni! " <br /> i 4. ❑ SANITATION PERMIT <br /> Job Address/L cati n ' <br /> Ow er s f - -."�-0_? - Address <br /> �J� 1? - C�'LEACHING FIELD ❑" EEPAGE PIT PACKAGE PLANT 0 <br /> Lff�EPT1C TANK ❑ PCESSPOQL © OTHER <br /> L'] PERMANENT-) ❑ TEMPORARY ❑ NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> Type Construction # <br /> No. of Units : Equipment Storage/Cleaning Location(s) <br /> t fi. ❑ PACKAGE TREATMENT PLANT aFgr Ju1yy1, -June 30, 19 Where Certified t <br /> i IEi <br /> dperator Name ) I, <br /> Plant-Location <br /> No. Units,Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: . ❑ Less Than 1,000 Sq. Ft., ❑ More Than"1,000 Sq..Ft: . <br /> 0: Y CLEANING, Chemicals Used/Amount/Mo. <br /> -- <br /> • :_ a ' <br /> I hereby d tr"at )1e work will be done',m accordance with San Joaquin County <br /> certify that I have prepared this applicationanf <br /> Ar ordinances, state laws, and rules 'regulations of the IS Irl Local Health District. " <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPAR: MENT"USE ONLY s lk fir,, <br /> j • <br /> Feels{?i1e ❑ ANNUALLY ❑ PER UNIT'" ,;- PER SITE,. " ❑ QCH ❑ January 1 R Received By January 3t" ❑ July 1 8 Receiv REMIT <br /> d By uIy 3� <br /> V BILLING. ) REMITTANCE— $ AMOUNT DUE `:CHECKED . <br /> �'`• - BASE EPLANAl-IpN + <br /> DATE e DATE-. REMITTED '.AMOUNT <br /> f. FEE <br /> LESS <br /> t: PRORATION - <br /> PLUS n.\ti J, <br /> PENALTY <br /> '.�, f d <br /> r OTHER �s' ;y �^ r t <br /> µ' OTHER <br /> a -7 �].l o D. <br /> Y - Date Receipt No. Permit No. Issuance Date ailed D ere <br /> \ Received by <br /> '16U1 E.HA2ELTON AVE.,AYEP.O.Box 2009 STOC f N>CA 20t / <br /> -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTISERYICES J� �7 <br />