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- - -- _ ­9-- <br /> a nc mppncatlon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Applicatio h Eby m e to rry on siness in the jurisdictional area of the San Joa uin ocal eal D' r' <br /> y Business N me (DBA.) 'vmoi _Address ei <br /> aOwner ,-_� Address DS $' <br /> Firm Partners. Addresses and Telephone Numbers <br /> iBusiness Telephone No. _ S�IoJ oZ6 f� <br /> QL Emergency Telephone N <br /> Contractor Licence No. o. <br /> _ <br /> 4 <br /> Applicants Name (Print)_ _ Title ' <br /> Please check Applicable Cat e9ry o (1-7) an ation <br /> — Date— n <br /> l <br /> t. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 6 <br /> Y�16 <br /> For July 1, _---June 30, 19 Disposal Sites <br /> Description (Make/Yr„ Color) <br /> Serial No. CAL. License No. <br /> CAL. Licc.-ise Renewal No, <br /> Capacity_ Gal., Weights 8 Measures No. <br /> Equipment Parking Address - - <br /> 2.:.❑ PUMPER YARD <br /> -i <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 / )J r� <br /> Job Addre Lo`ation f J�.3 IL(/ /j,=��^l"' <br /> Owner Address U p <br /> 10 SEPTI TAN ❑ CESSPOOL LEACHING FIELD 1:11 SEEPAGE PIT ^PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY KNEW ❑ <br /> REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June.30. 19_ <br /> Type Construction_ Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) —� <br /> 1 ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name _- <br /> Where Certified <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 /> a <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ani <br /> ordinances, state law ules and reg lations f the San Joaquin Local Health District. <br /> • <br /> APPLICANTS SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH 'r <br /> ❑ January 1 &Received By January 31 ❑ Jury 1 & Received By JUIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT J <br /> DATE DATE REMITTED AMOUNT DUE CHECKED 1 <br /> FEE / <br /> AMOUNT <br /> LESS H� <br /> PRORAT;ON - <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER 1 <br /> OTHER - <br /> 6 <br /> Received by Date Receipt No. ' Permit No. � <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERYICES Issuan a Date Mailed Deliver <br /> 1501 E.HAZELTON AYE.,P.O.Box 2009 STOC TON, 95201 <br /> � I <br />