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Irl QOMPlelea,oa - - <br /> Applications WIN Se P��cessed When Submiried Props Y <br /> APPLICATION <br /> (For Non-Transterable,Revocable,and Suspendable) $EpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> 1a �s o GA- 9s�Ss <br /> application is hereby made to carryon business in the yurisdictinnaAddressarea of thp�Jo oath Local Health District <br /> e E <br /> ,� i <br /> w9usiness Name (,eA) Address <br /> i9Owner <br /> Firm Partners,Addresses and Telephone Numbers Emergency Telephone No. <br /> �r-�27,h 7- <br /> IL Business Telephone No. <br /> !« TitleDate <br /> f Contractor Licence Na. ea.� <br /> 9Applicants Name(Print) Wred Information <br /> Please check Applicable Req <br /> Category (1-7}and Fill in the <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION IDOFo aICS es VEHICLE) <br /> For July 1, June 30, 19 � <br /> CAL. LIcc;ase Renewal NO. <br /> Description(Make/Yr.,Color) f CAL.License No. <br /> Serial Na. Gal..Weights&Measures No. <br /> Capacity <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 R.S.or R.C.E.No. <br /> R.S.or R.C.E.Name Test Date/Time <br /> € Test Location <br /> q, ❑ SANITATION PERMIT <br /> Job AddresslLocation Address <br /> Owner ❑ PACKAGE PLANT <br /> SEPTIC TANK 13 CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT C3 OTHER <br /> i <br /> [3 PERMANENT C3 TEMPORARY- D NEW TM REPAIR <br /> ( 5, ❑ CHEMICAL TOILETS For July 1. June 30, 1pispo Disposal Slte <br /> Type Construction <br /> ( No.of Units Equipment Storage/Cleaning Location(s) <br /> 1 6. ❑ PACKAGE TREATMENT PLANT I For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> i Plant Location No.Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 1 ,000 Sq. Ft. <br /> Cl SMore Than 1 <br /> ' SIZE'. [3 Jess Than 1,000 Sq. Ft.. <br /> ❑ DRY CLEANING,Chemicals Used/A.ount/MO. <br /> f # if that I have prepared this application and that the work will be done in accord ce Iih San Joa in unty <br /> I hereby cert Y <br /> e tions of the San Joaquin Local Health Distrlct: <br /> ordinances,state laws.and ruland regula <br /> APPLICANT'S StGNATUREX i - <br /> ( FOR DEPARTMENT USE ONLY <br /> .❑PER SITE 0 EACH © January 1 6 Received ay January.3t ❑ July 5 8 Received ey July 71 <br /> 1 REME7 <br /> L, Fee IS Due:❑ ANNUALLY ❑ PER UNIT REMITTANCE 3 AMOUNT DUE CHECKED <br /> p BILLING REMITTED' AMOLINT <br /> BASE- EXPLANATION HATE PATE <br /> I <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I ' <br /> r OTHER <br /> Permit No. <br /> 155LIanLa ate Mailed Delivered <br /> ReceI NO. <br /> ' RDate 1601 E.HAYELTOfl AYE., O <br /> P. ,Box 2009 STOCKTON;GA 95201 <br /> eceived hY ENVIRONMENTAL HEALTH PERUIITISERVICES <br /> -APPLICANT—.RETURN ALL COPIE970: J� <br />