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App1lLAtlo,•+W•11 Be Processed Whmn Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Yon-Transl•rable. Revocable,and Suspendoble) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiwahgn is he-eby made to carry on business In the lunsd ctr:nal area of the San Jogquin local Hea lb District <br /> Address tI'l <br /> i C'wr•er t�1 s.� ,t' �( / 1�fes'..j. _ ^Addross ✓ ` �`a++" 7e 7 <br /> It <br /> J Firm partners Addresses and Telephone Numbers <br /> 3C,+ ' .rl t S <br /> QL fFuarneSS Telephone No Emergency Telephone No - <br /> Contractor Licence No -'-,ee 2 C <br /> ADDircamn Name(Print) r-f'ti k'i 7 - f�. (.1)a-ra? /t Title �C-5 Date -7`1 <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 /> DescrlpbOn(Make:Yr,Color) -- _. - - -- - <br /> Serial No CAL- License NO _.CAL.Liw-se Renewal No. <br /> Capacity Gal-.Weights R Measures No _- _-- - --- ------ ------------------- ---V <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1. June 30, 19 <br /> NO of Vehicles Stored - - ------ - ------ --- -- --- - -No Of Chemical Toilets Stored - • <br /> 3. ❑ PERCOLATION TEST <br /> RCE. No <br /> R 5 or R C.E Name RS. or ----- ---"—-� <br /> Tr,,;L,,cat•.n G Test nate/Time ---� <br /> 6. ❑ SANITATION PERMIT <br /> Job ActdresS'Lamualiorl ♦ <br /> ( �rJJAddrtss .�P*.re ^ N�,S fig* r.(c .cr <br /> Owner �-1 a /�+[ /sTr _ hi tLrG/+:f[n 4s r� v <br /> 1R SEDT!C TANK ❑ CESSPOOL LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY I3 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Jnne 30, 19 <br /> Type Construction Disposal Site______.No of Units Equipment Storage/Cleaning Location($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1.-June 30. 19 <br /> Operator Name 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 SO Ft. ❑ More Thai 1,000 Sq Ft <br /> ❑ DRY CLEANING,Chemicals Used'Amount/Mo <br /> I hereby certify that I haze prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinanf.esstate lawsand rules and regulation�syol the San Joaquin Local Health District <br /> APPLICANT S SIGNATURE X �'�=' <br /> I FOR DEPARTMENT USE ONLY <br /> Fee IS Due. ❑ A14'1.1A-1 r ❑ PER UNIT ❑ PER SITE ❑ FAC 14 ❑ J.rnua, t 6 uec n,.nh By Ja"ua•y 31 ❑ July t a Rn---'I BV July I <br /> REMIT <br /> BA,E EXPLANATION RILIJNG REMITTANCE S AMOUNT DUE CHECKED <br /> DATF DATE REMITTED AMOUNT <br /> FEE <br /> LESS /J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f . <br /> l;THEN <br /> per n.:Nl nr Ua1+ H.•�n.(1 /t ['r•m.1 f::, rl7ira..rA Uste M+I,H Ur•':ele7 ! <br /> L_ _ - APPLICANT—RETURN All COPIES TO ENVIRONMENTAL HEALTH PERMIT SERVICES 1601 E.HAZELTON AVE.P 0 am 20M STpCKTOR CA ssmT T <br />