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Applications Will Be Processed When Submitted Properly Completed. Be Sure 1 o sign I lie Appucaslon. <br /> APPLICATION <br /> I (rur Non-Transferable, Revocable, and Suspendable) <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Fy Application is Yiereby made to carry on business in the jurisdictional area of the San Joa uin Local_Health District <br /> �8usiness Name <br /> (DBA) <br /> ��" -rte Address - <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q.Q. Business Telephone No. f ` �� Emergency Telephone No. <br /> Q. <br /> Contractor Licence No. _ s <br /> Applicants Name {Print) ! � �1C - Title Date L` 7 <br /> 'Please check Applicable Category (1-7) and Fill in the Required Information <br /> r <br /> 1. 11PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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 /> t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L� ation ` Test Date/Time <br /> 4. ® SANITATION PERMIT _ i <br /> Job Address/Location I L- 2-- <'� "` _C <br /> Owner 1 .Ei U r , AddressC r <br /> ❑ SEPTIC TANK © CESSPOOL ❑ LEACHING FIELD E SE�AGE PIT ❑'PACKAGE PLANT d <br />�• ❑ PERMANENT ❑ TEMPORARY ❑ NEW La-REPAIR ❑ OTHER <br /> I5. 1:1CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> 3 i 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 /> F Operator Name Where Certified S <br />{ Plant Location <br /> Plant Capacity No. Units Served <br /> 1 f 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a <br /> t �I' <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 r ?Mations of the Sa qujn Local Health District. <br /> APPLICANT'S SIGNATURE <br />� - I <br /> y rrvv FOR DEPARTMENT USE ONL' <br />} Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LXPER SITE ❑ EACH ❑ Jap a�" &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 REMIT <br /> BASE EXPLANATION BILLING READATE AMOUNT DUE CHECKED <br /> FEk+t DATE DATE REMITTED AMOUNT <br /> 4 FEE <br /> LESS <br /> PRORATION , <br /> PLUS I } <br /> PENALTY ! <br /> OTHER II i <br /> i <br /> OTHER 'r <br /> F�t <br /> 1,, 1 <br /> I Received Lv Dale Receipt r4o Pevmll No ssuance C to Mailed Delivered <br /> APPLICANT—RETUFIN ALL Cq PIES TO. ENVIRONMENTAL HEALTH PERM17,SERVICES 1601 E.HAZEL7ON AYE..P.C.Box 2009 STOCKT ON.CA 95201 <br />