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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application.
<br /> APPLICATION
<br /> f (For Non-Transferable,Revocable,and Suspendable)
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> App!-cat on Khereby m e to cptry rbusiness in Ae jurisdictional area of th J u,n Locat H��atth 1��r,c.l� moo_
<br /> F Business Name(DBA) id�- _ Addressrf +Y�-i'/w
<br /> z Owner > _— �l�_ Address _ /44p� Al.
<br /> SL
<br /> a
<br /> 7 Firm Partners, Addresses and Telephone Numbers -- � �
<br /> Business Telephone No. Emergency Telephone No.
<br /> Contractor Licence No.
<br /> a
<br /> Applicants Name(Print) _ (.„>Jt /� � Title �S 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 ,,ply 1. _- June 30, 19 _ Disposal Sites -__--_-.-__--
<br /> Description(Make/Yr.,Color)
<br /> Serial No. CAL.License No. ____--._ _._. CAL.License Renewal No.____—.__
<br /> Capacity Gal.,Weights&Measures No
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD - --_—-•__--_--
<br /> For July 1•__ June 30,19
<br /> F
<br /> No.Of Vehicles Stored
<br /> ;a No.of Chemical Toilets Stored
<br /> p 3. ❑ PERCOLATION TEST
<br /> R.S.or R.C.E.Name -- i —_—_-_-,—__ R.S.Or R.C.E.No.
<br /> {
<br /> Tesbpcation _, _____ Test Date/Time
<br /> f 1. SANITATION PERMIT- O(A
<br /> Job Ad ss/Lova'on �Z� — �
<br /> y O�yner QA!liL Address QZlix-
<br /> 1�s'SEPTIC TANK CESSPOOLV LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT
<br /> gPERMANENT O TEMPORARY WNEW G REPAIR ❑ OTHER N��� dnl►N��r
<br /> Y S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Type Construction Disposal Site
<br /> No.of Units _ Equipment Storage/Cleaning Location(s)
<br /> i
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19
<br /> Operator Name — Whara Certified
<br /> Plant Location
<br /> 1 Plant Capacity____- —.—No.Units Served
<br /> I 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/AmounVMo, —_
<br /> Ho;-re owner or licOnw agent'e RtpnRh,n1 eMtifies 1M fotlpyytnq;"I�rKiN rt_Ti 1.rl•p..;•,.,. .:..
<br /> in s,ch M'anner:Ir to Qac mr sulMac: ,Irtn�n, r n.r�1i!Fr-sr;. .lc.`;'
<br /> - COntMG[Or'R hi`�rt0 1 •dl+ .'d', '1 r'di�.Jf:+h•
<br /> C^ 0 Wb•fvthAaliMl I»�nn��.. om:' a, rne`,w V ,..,,...,. .
<br /> ;.:n,IR�,.>nss�AlLtt t�::cN.mr•.c:,,,►�as;ac.. ... . ...�,.,... . .,- _ '. .:•v•xCic'i'J:Is;:^...
<br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Cou
<br /> ordinances,state laws,a rules and reg tions of n Joaquin Local Health District.
<br /> ry APPLICANT'S SIGNATURE x ---- — ----
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY .O PER UNIT ❑PER SITE O EACH ❑ January t A RecRntd By JRnwry Jt ❑July t a RRcem-d I
<br /> BASE — E%PLANAT*N BILLING REMITTANCE _ f AMOUNT DUE CHET
<br /> DATE DATE REMITTED AMC
<br /> -------- ------ ----
<br /> FEEclka
<br /> L
<br /> LESS -- ----- ---
<br /> PRORATION
<br /> PLUS
<br /> PFNALTY
<br /> OTHE9
<br /> OTHER....-------} _ -'-- ---- ---.—_--- _---- —-- --- - ----
<br /> -T5
<br /> nocr+ved by DRIn Rtanpt No Termd No -�iRw DRU aiNO ONworea
<br /> ---- APPLICANT--RETUnN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 10011.HAZELTON AVE.,C.O.Oft 700! STOCKTON,CA
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