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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application, e�,? - / <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> r ENVIRONMENTAL HEALTH PERMITSl / E <br /> .a LIQUID WASTE <br /> i <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name {DBA)_ �% ,^C l�� <br /> Address <br /> 4 Owner �C � _— Address <br /> J Firm Partners, Addresses and Teie�hone Numbers _ <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ���f ' <br /> L Applicants Name (Print) � Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> i. ❑ PUMPER VEHICLE PERMIT.REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> t Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL.. Licc:lse Renewal No. <br /> r'-' Capacity Gal., Weights & Measures No.. <br /> I Equipment Parking Address <br />' 2. ❑ PUMPER YARD <br /> Far July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> I 3. ❑ PERCOLATION TEST <br />' R.S, or R.C.E. Name R.S. or R.C.E. No. <br /> Test ocation Test pate/Time <br /> 4. SANITATION PERMIT�y -� " <br /> Job Address/Locationts Ir <br /> R <br /> Owner � � IJD Z � !fis��' _ Address 331L D -'. <br /> s' SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY J NEW ❑ REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -` <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> &. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �� <br /> ;- T� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> F ordinances, state laws, an a nd regulation of the SayJ aquin Local Health District. <br /> APPLICANT'S SIGNATURE X 1 <br /> F," <br /> FOR DEPARTMENT USE ONLY <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT OsPER SITE El EACH ❑ January 1 &Received By January 51 ❑ July 1 &Received ByJuly 31 <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED I <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ; <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> . _ I <br /> 3 ��+, <br /> Received by Date— Receipt No. Permit No Issuance Date Mailed �ve <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HATELTON AVE.,P.O.Box 2009 STOC OH- A3520 <br />