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APPLICATION <br /> .ir Non-Transferable, Pevocable, and SuspendaL ' <br /> ENVIRONMENTAL HEALTH PERMIT1 SE�TAG= <br /> LIQUID WASTE <br /> i Application is h by made to carry ria business in the jurisdictional area of t San oaquin Loll Health District <br /> [Business Name (DBA) 1 $ Address �- <br /> z_owner Address' <br /> Partners, Addresses and 7efept}gne IVumefs <br /> Firm <br /> usiness Telephone No. -T 6 Emergency Telephone No, <br /> Contractor Licence No. <br /> 1i applicants Name (Print) Title 4^S77 Date <br /> =tease 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 /> 3escription(Make/Yr., Color) <br /> r3erial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> F-.quipment Parking Address <br /> ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> ,,,ala.of Vehicles Stored <br /> Bio. of Chemical Toilets Stored <br /> J. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E_No. <br /> res!ycation Test Date/Time <br /> 911111 SANITATION PERMIT <br /> Job Addre Location ajTar + <br /> caner Address + <br /> Si;PTIC TAMC ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PL NT <br /> ( PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30,19 <br /> F�jo. <br /> ype Construction Disposal Site <br /> of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> dperator Name Where Certified <br /> ant Location <br /> Plant Capacity - No. Units Served <br /> r ❑ LAUNDRY For July 1, -June 30, 19 <br /> ZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> J DRY CLEANING,Chemicals Used/Amount/Mo, <br /> I <br /> i <br /> . i <br /> 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 ru and regal tions of a an Joaquin Local Health District. <br /> 17A I <br /> FIPPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑July t e,Received By Juty 31 <br /> REMIT l <br /> BILLING REMITTANCE S <br /> } BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ell's I ,�, 3 <br /> LESS <br /> I PRORATION <br /> a <br /> PLUS / <br /> PENALTY 'L <br /> 9 <br /> OTHER <br /> t ' <br /> OTHER <br /> 31 <br /> Received by - -_- Dale Receipt No. Permit No. lUS a al Mailed pefivered 3 <br /> t , <br />