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Applications Will Be Processed When SuAPPLICbmitted ProAperly <br /> co pletea,ue,uFv a �,a„ rr•- <br /> (For Non-Transferable,Revocable,and Suspendabie) $EpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereeby made to carry on business in the jurisdictional area of the San oaquin Loc�a/l Health District <br /> �� --�-c��� <br /> y Add ressBusiness Name(DBA) 41 t_4 <br /> Address <br /> aOwner_ —.A-4--/-' <br /> j Firm Partners, Addresses and Telephone Numbers Emergency Telephone No- <br /> J -------------- <br /> o. <br /> aBusiness Telephone No. Date <br /> Contractor Licence No.�� '4 f J ��� Title - - <br /> Applicants Name (Print) � <br /> the Required Information <br /> Please check Applicable Category(1-7)and Fill in <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(DOR EACsal H VEHICLE) <br /> For July 1, June 30, 19 <br /> es <br /> Description(Make/Yr.,Color) CAL.License No. ____CAL License Renewal No. <br /> Serial No. <br /> Gal.,Weights 8,Measures No. <br /> Capacity <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 TESTNo ' <br /> R.S.or R.C.E.. . , <br /> R.S.or R.G.E.Name Test Date/Time <br /> Test Location 4107— M— <br /> A. ❑ SANITATION PERMIT N —` <br /> Job Address/Locatio1 G <br /> Address <br /> Owner _ ❑ PACKAGE PLANT <br /> 1 -tFPTIC TANK El CESSPOOL �CEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IJ REPAIR <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30,19 <br /> type Construction <br /> Disposal Site <br /> No.of Units Equipment Storage/Cleaning Ldcation(s) <br /> g. 13 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified CA <br /> Operator Name <br /> Plant Location — No, Units Served <br /> Plant Capacity <br /> 7• ❑ LAUNDRY For July 1,-June 30,19 <br /> SIZE: ❑ Less Than 1;o00 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 r gut Iions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> • <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:❑ ANNUALLY C3 PER UNIT 13 PER SITE ❑ EACH ❑ January 1 eceived By January 31 ❑July 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> BASE E-XPLA14ATION DATE DATE REMITTED AMOUNT <br /> FEE ✓ ---- <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY S - <br /> OTHER <br /> OTHER 7 <br /> - Permit` Is a Date Maiied Delivered <br /> Received by Date Receipt No. <br /> :�- APPLICANT=RETURN AI.L COPIES TO: ••ENVIRONMENTAL HEAJ-TH PERMITISERVICES <br /> 1601 E.HAZELTON AYH.,P.O.Sox 2009 STOGKTON.CA 85201 <br />