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rr.. ...... ........ . ..,.�,,�.. ....c..v..�n14—C—pcny vv IVIVWU. vc aurc I aryn me PAPPuvauun. <br /> APPLICATION <br /> sir Non-Transferable, Revocable, and Suspendat q� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio i er by made to carry nnbu,^,in ss in the�urisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) I Gf c'S ► �4 �1G Address j� i�„'j 1 c�' lot"- (� <br /> a Owner 1 //4) C'�12�t jAddress t'Ill <br /> J Firm Partners, Addresses and Telephone Numbers C <br /> 0- Business Telephone No. �t <br /> P Emergency Telephone No. f <br /> Contractor Licence No. 29 3C1! 1 <br /> Applicants Name (Print) (Z CA(Zctjr Title Date <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 /> Description(Make/Yr., Color)_ <br /> Serial No. CAL. License No. CAL. Licz:nae 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location _ Test Date/Time <br /> 4. ❑ SANITATION PERM13 / <br /> Job Address/Location <br /> Owner Address-/0300 ' r: /`r /I74tlz vh O <br /> ❑ SEPTIC TANK ❑ CESSPOOL R LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site AQ <br /> No. of Units _ Equipment Storage/Cleaning Location(s) N <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 0 <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 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 regulations of the San Joaqe Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT qPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> /q- <br /> OTHER <br /> -7110130 37LS 04Ys1 _7 r6 0 <br /> Received by Date f Receipt No. Permit No. Issu nce Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCI�TON,CA 201 <br /> C <br />