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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTneAppucauon. <br /> _ APPLICATION <br /> } (For Non-Transferable, Revocable,and Suspendable) SE!'TAGE <br /> ENVIRONMENTAL HEALTH PERMIT x <br /> LIQUID WASTE . <br /> r Application is hereby made to carry on business in the jurisdictional area of the n Joauijn local Health District , <br /> /J <br /> . Address <br /> rBusiness Name (DB )� /I- , ;S <br /> r- A <br /> t�z Owner— ddress <br /> • .�e r��G <br /> ,Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone Na. <br /> Contractor Licence No. y <br /> Title ��f Date%.t�® .•-.�"� <br /> L Applicants Name (Print) x <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. Liccnae Renewal No. <br /> Capacity Gal.,Weights &.Masures..No-. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 4 <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. orR'C'E'NameR:S orR'C:E-No'-T-_""._�� .-�-- <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> ` <br /> ...�� -^ate <br /> Ow � � �^ Addresses <br /> ,,, ❑ PACKAGE PLANT l <br /> Lfd'SEPTICr TANK ❑ CESSPOOL IF-LEACHING FIELD ID SEEPAGE PIT 1 <br /> ❑ PERMANENT ❑ TEMPORARYNEW *❑ REPAIR ❑ OTHER <br /> A... <br /> f 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site t + <br /> Type Construction t <br /> No. of Units Equipment Storage/Cleaning„Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 <br /> Certified <br /> Operator Name 11h- <br /> -Where <br /> Plant Location <br /> Plant Capacity R 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. �.- a <br /> f .77” <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 an regul tions- he San-Joaquin.Local,Health District. + <br /> APPLICANT'S SIGNATURE X tF <br /> T .f' <br /> T .L FOR DEPARTMENT USE ONLY y <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT- ER SITE ❑ EACH 0 January'TWFR6ceived'By,iiinuafy 31. ` ❑ July 1 &Received By July 31 <br /> REMIT <br /> F BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ORTE DATE E <br /> REMITTD AMOUNT <br /> FEE tv <br /> { <br /> LESS ► ""'�,� � ; <br /> PRORATIONPLQS <br /> PENALTY J y <br /> -OTHER <br /> r <br /> OTHER ' ,. <br /> r <br /> Received by °` Date Receipt No. Permit c. Issuance Date. Mailed livere - <br /> r <br /> 'APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERV 1601 E.HAZELTON AVE.,P.O.Bo:2099 STOCK N,CA 95 1 <br />