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'- APPLICATION <br /> Non-Transferable, Revocable;and Suspendabn 5E? AG <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE n <br /> Application is eby made to carry o�business siin the jurisdictional area of th an JQaquin Locaealt District <br /> yBusiness Name (DB �4 Address <br /> z Owner Address <br /> j Firm Partners,Addresses and Telepho Numbers <br /> aBusiness Telephone No, C-166—c'6 O Emergency Telephone No. <br /> Contractor Licence No. <br /> 4L Applicants Name(Print, - 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.License Renewal No. r n <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 PERMIT L1 E <br /> Job Addr� ,.. <br /> ees//s/.Locati9 mAy <br /> � /�a Qe 94d <br /> -{[ <br /> Owner �� ogo Address/0 91 4 Un. 99 �� f�P <br /> ❑,/SEPTIC TANK ❑ CESSPOOL ❑ LEACHiNG FIELD X SEEPAGE PIT X PACKAGE PLANT <br /> pl PERMANENT ❑ TEMPORARY NEW ;KREPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 J-NTfgC.Ff*i--, <br /> T e 6nstruction Disposal Site, <br /> 3y-pe op <br /> No. of Units Equipment Storage/Cleaning Location(s1. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 . <br /> Operator Name Where Cer'iifle&r <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 h <br /> I hereby certify that I have prepared this application and that the work will be done irU=accordance with San Joaquin County <br /> ordinances, state laws, and r es and re ula ons oft n Jda�uln Local Health District. <br /> APPLICANT'S SIGNATURE X fe6l -� <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH. '[].January 1 &Received By'January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ' BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 'AMOUNT <br /> FEE2 `rt <br /> i LESS <br /> PRORATION <br /> IIS <br /> PLUS <br /> E PENALTY <br /> OTHER T <br /> OTHER <br /> Received by pate Receipt No. --Permit No Is rice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 ELTON AVE.,P.O.Box 2009 $TOCKTON,CA 95201 <br />