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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. y <br /> f APPLICATION / <br /> ., (For Non-Transferable, Revocable, and Suspendable) Q� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I <br /> LIQUID WASTE �?.r <br /> Applicati er-by made to carry�6bu In ss in thejurisdictional area of the San Joaquin Loal Health District <br /> Business Name (DBA) <br /> } 61 C5 I � �b ��Z Address <br /> i Owner / ' G i Address <br /> Firm Pa--rtners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �-2 3 `' 'e Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) I i i}[yyR ,l le 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 /> d <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. LiCc�se Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> 7 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored # <br /> ( <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 ~ <br /> r: <br /> 4. ❑ SANITATION PERMITO I <br /> Jot? Address/Location <br /> Owner is. z. 'II Address to 301 <br /> ❑ SEPTIC TANK ❑ CESSPOOL R LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHERS <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> A <br /> Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) N <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Q" <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For.July 1,-June 30, 19 <br /> SIZE: ❑ Less Than f.000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> C3 DRY CLEANING, Cliemicals 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 rules and regulations of the <br /> San JoaqyP Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> i <br /> FOR DEPARTMENT USE ONLY S <br /> Fee I5 Due: 13 ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &ReceiveRdEByl July 31 .. <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ]/ AMOUNT <br /> I FEE r �+ <br /> LESS <br /> PRORATION <br /> - l <br /> PLUS <br /> PENALTY <br />` OTHER <br /> i <br /> ` OTHER <br /> r <br /> I - S (b (� �o <br /> 1 to BU 3� 5 - t ? <br /> ! Received by Date Receipt No Permit No. Issu nce Date- _ Mailed Deliver d- <br /> F - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005 STOIC ON,CA 201 <br /> F L� <br />