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Applications Will Be Processed When Submitted Properly Gomplelleo. ae ourc it, ,lull 1— <br /> APPLICATION —APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> SE PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k LIQUID WASTE <br /> Application'is hereby made to carry on business in the jurisdictional area of theSanJoaquin Local eal.thD�trict 0 <br /> mBusiness Name (DBA) Ai7" Snit Address <br /> I a Owner <br /> Cc, /)A%/j4V�,. Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. <br /> 2-.3 V �'/ 7 Emergency Telephone No. <br /> � <br /> Contractor Licence No. Date <br /> LApplicants Name (Print) G ��_ Hsi O 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 <br /> Description(Make/Yr., Color) CAL Licc^se Renewral No, <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. _ <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 /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> I TTest Date/Time <br /> Test Location R <br /> f 4. ❑ SANITATION PERMIT /3� f►�c/�Yf:+C/1r��f/ /I� <br /> Job Address/Location & �"� <br /> /3 a e7_1ri" 4F1 e"- ,r/se's Address sf',•�`" �.�s %C u✓C'Owner PLANT <br /> ® SEPTIC TANK El CESSPOOL 11 LEACHING FIELD 1:1 SEEPAGE PIT El F� ZT�y )3'-el <br /> i <br /> O PERMANENT 11 TEMPORARY RINEW 11 REPAIR Q OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> t No. of Units Equipment Storage/Cleaning Location(s) -- <br /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified � <br /> Operator Name <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. n <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> � have prepared this application and that the work will be done in accordance with San Joaquin Country <br /> I hereby certify-that I <br /> ordinances, state laws, and iLles and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X /!/ <br /> FOR DEPARTMENT USE ONLY <br /> f Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE ❑ EACH _❑ January 1 &Received By January 31 El July 1 &ReceivedJuly 31 <br /> REW <br /> EXPLANATION BILLING RE ITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> + DATE DATE REMITTED AMOUNT <br /> k FEE <br /> LESS _ <br /> PRORATION ` <br /> s PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receive y <br /> - Date' Pt o. Permit No Issuance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661.E.HAZELTON AVE.,P.O.Box 20D9. STOCKTON,CA 95201 <br /> } ! <br />