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�a <br /> Applications Will Be Processed When Submitted Properly Completed Be Sure To Sign The Applicnticn. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1` ' <br /> r'pplicatlon Ig hereby made to carry on ousiness in the jun�dictional area of the San Joaquin Local Health D�,; nc; . <br /> Business Nnmo.(DBA) �cu'� l� f ; „+,<� .lei X'nV Address J' ��Y`) -26 l �` <br /> Owner .- . r 1r Z i L Address 7C-1 <br /> J Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone Na _.___S d / �'`S_ _ Emergency Teleph,ne No <br /> Contractor Licence No. <br /> i Applicants Name(Print) .______-ET.J 2<• �.� t' C e-C<<< Title - C c< "-< a. 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 Lid,Tse Renewal No <br /> Capacity ____—.. Gal,Weights&Mr.isures No. ' <br /> Equipment Parking Address ...__ <br /> 2. ❑ PUMPER YARD i. <br /> For July 1,_ ___—__ Juno 30. 19 , <br /> No.of Vehicles Stored .__ <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST O <br /> R.S.or R.C.E.Name ---- —-- -- R.S.or R.C.E.No. - -- - - - b <br /> Test 1-9efition —.—_ _—__. __ __ _ _ ____ _ Test Date/Time <br /> 4. RrSANITATION PERMI7 <br /> Job Address/Location _— $fes -��. --r <br /> Owner Address -- -- <br /> SEPTIC T 13CES.'!POOL Lg LEACHING FIELD SEEPAGE PIT ❑ PA AGE LA 'T <br /> ®PERMANENT ❑ TEMPORARY LTf NEW REPAIR 13OTHER T� <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> r, <br /> Type Construction _—._.__._....... DIa^ sal Site,- <br /> No.of Units _---___ Equipment btoraye/Cleaning Locallon(s) <br /> 6. ❑ PACKAGE TREATMENT FLANT For July i,-June 30, 19 <br /> Operator I"ama - ---.---.._.____ --_- _ Where CeA(fiW <br /> Plan+Location <br /> Plant Capacity —_ __ _ No.Units Served <br /> ;,e <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. <br /> ❑ DRY CLEANING,Chemicals Ustd,'Amount/MO. <br /> I hereby certify that I have 3repared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state laws,and niles and requlations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER U,vIT ❑ PER SITE ❑EACH ❑ January 1 a Received By January 31 ❑July 1 d Rece'VM By July 11 <br /> REMIT <br /> BILLING REMITTANCE 1 <br /> BASE E%i LANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT ; <br /> FEE /flys r:l. <�.,� _.._ .. <br /> LE19 <br /> PRORATION _ - - -----_- _ .- -•- <br /> PLUS------- — <br /> PENALTY _ .. <br /> OTHER i <br /> OTHER l <br /> Received Dy Date R✓ce•.pt No Pxmrl No Issuance Dete d trvm <br /> -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH VERMI'i/SERVICES 1001 E.HA2ELTON !OW/'TOCVTON CA"101— <br />