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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) j <br /> �I ENVIRONME T HEALTH PERMIT <br /> LIQUID WASTE <br /> � ' �pTAGi= <br /> Applicatio ' h eby pmde)oparpy-elrt9uBirxns in the jurisdictional area of the S Joa Local Health Djsgict <br /> FB <br /> usiness N (DBA} J AddresQ <br /> z Owner ez'Oe E Address _?6(ell rO rr t <br /> I <br /> Firm Partners, Addresses and T le�ihonet�Numbers 3 <br /> IL Business Telephone No. 3�Y '7 33 Emergency Telephone No. 4l, <br /> Contractor Licence No. <br /> LApplicants Name (P ek Title Date <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 <br /> Description (Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. i <br /> Capacity Gal., Weights & Measures No. Q } <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD J <br /> For July 1, June 30, 19 Q ' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored Y <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �"- <br /> Test Location Test tate/Time <br /> 4. SANITATION PERMIT <br /> Job Addre ILocatio <br /> Owner ,�..�ndoM�� Addres,.s-,�U � � OC �Galrl <br /> SEPTIC TAN © CE55P OL 8'LEACHING FIELD I�SEEPAGE PIT ❑ PACKAG PLANT <br /> 31PERMANENT ❑ TEMPORARY 2-NEW ❑ REPAIR ❑ OTHER <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., ❑ More Than 1,000 Sq, Ft. T <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r , <br /> �i <br /> f <br /> I hereby certifythat I have pre d this a lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and nd regul o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January ,&Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE T E $ AMOUNT DUE CHECKED <br /> DATE E REMITTED AMOUNT <br /> FEE <br /> LESS ` <br /> .PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER .. <br /> i <br /> OTHER <br /> e,ved b Date �h> 7 Receipt No. Permit No. Issuance Dat Mailed Deli red - <br /> w A LICANT--RE UAN ALL COPIE TO: E101RONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAVE.,P.O.Box 2009 -ST KION, A 95201 . <br />