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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) $t=p7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application I hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> Z. <br /> OF Business Name (DBA) Address �� <br />,a Owner . ;� � Address <br />.0 Firm Partners, Addresses and Telephone Numbers 'J i` <br /> aBusiness Telephone No. Shy Emergency Telephone No. <br /> � Contractor Licence No. _ <br /> 67 9-0� <br /> Applicants Name (Print) „ �fG�� Title �-�'"�� <br /> Please check Applicable Category (1-7) and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) k <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 July1;.. ^Jurie 30;.1,9._ <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TESTR.S. or R.CC.� .E. No. <br /> R.S. or R.C.E. Name R.S. or <br /> Test Date/Time <br /> Test Locations- -- r <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Ownerr _ Address Z <br /> 2-SEPTIC TANK ❑ CESSPOOL LEACHING FIELD❑ SEEPAGE PIT C3 PACKAGE PLANT <br /> + j <br /> ❑ PERMANENT ❑ TEMPORARY : NEW ❑ REPAIR ❑ OTHER + <br /> k <br /> 5. 1-1 CHEMICAL TOILETS--For-July 1,—June 30,49--�X <br /> �4 I <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 NameY Where Certified (� <br /> ` <br /> No: <br /> Plant Location It Units Served <br /> z \,� <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 /> ❑ DRY CLEANING, Chemicals Used/Amon UMo`� <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 �andegullations of the San Joaquin Local Health District. <br /> 7 <br /> APPLICANT'S SIGNATURE X �T <br /> i t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> �AMOUNT <br /> REMITBASE EXPLANATION BILLING REMITTANCE $ E. CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE H� � <br /> LESS �..� <br /> PRORATION <br /> t — .PLUS r <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER _ <br /> o 13 mv/ fro <br /> ' Permit No. - Issuance Daae Mailed liver d <br /> k - Recelvetl by Oate Receipt No. <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.ao><2609 5T0 TON,C, 5201----70051, <br />