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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> WX APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) !�" q <br /> r SE PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �f�S <br /> LIQUID WASTE : <br /> Applicat' n is r made,t arry oness in t }e jurisdictional area of t�SSan(�aquinLooc/a�l al Distri t <br /> F r,6-m <br /> Business Name (DBA) , ( ' <br /> . a. �L..rL. Address✓ l <br /> a Owner Address <br /> L).Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.__y66-96(97 Emergency Telephone No. <br /> Contractor Licence No. r` <br /> L Applicants Name (Print) cT Title V r Date �_ _p 0 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i <br /> For July 1,-June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL, License No. CAL. License Renewal 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 <br /> R.S. or R.G.E. Name R.S.or R.C.E. No. i <br /> Test ocation Test Date/Time N <br /> 4, SANITATION PERMIT <br /> Job Addres oc to 13R, � PPP <br /> Owner Add <br /> r� ,{ Address <br /> 1:111 � <br /> SEPTIC TANK CESSPOOL qZ LEACHING FIELD g SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW UCREPAIR ❑ OTHER W ' <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 4 <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 /> 1 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, pyd rules and egulati f the rt Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> . a <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 11 ANNUALLY. 0 PER UNIT PLPER SITE 1:1 EACH © anua 1 &Received By January 31'` ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE T C $ AMOUNT DUE CHECKED <br /> DATE E REMITTED [� AMOUNT r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERell <br /> ` <br /> 74? <br /> Received by Date Receipt No. Permit No, Issuance ADate Mailed De ivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.-HAZELTON AVE.,P.O.Box 2009 STOCK N,CA 201 <br />