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Applications Will Be Processed When Submitted Properly Completed.,Be Sure To Sign'the Application.# <br /> APPLICATION •3 <br /> r (For Non-Transferable,Revocable,and Suspendable) _, .;$EPTAGE,;- _ <br /> ENVIRONMENTAL HEALTH:PERMIT - <br /> LIQUID WASTE <br /> Application is hereby made to carryon business inthhelunsdictional area of the an Joaquin Local Health Distrlc <br /> ., _Address O+ t.'J X �� <br /> w Business Name(DBA)7).A D 2 2 FG�14 S t <br /> aOwner _ Address <br /> s, Firm Partners,Addresses and Telephone Numbers r <br /> c Business.Telephone No. <br /> " p07 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title 4&-rnR—-- nate <br /> Please check Applicable Category(1-7)and Fill.in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30,-19' Disposal Sites - <br /> Description(Make/Yr.,Color) <br /> Serial No: CAL.License No. CAL.License Renewal No. " t` <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. .❑ PUMPER YARD <br /> Gly 1, June 30, 19 F <br /> /N.1.007 <br /> o VehiclesStoredl' o..of Chemical Toilets Stored - <br /> 3 P PERCOLATiON TEST~ <br /> R.S.or R.C.E.Name _ R.S.or R.C.E.No. <br /> Test,�..L�oc��at'on Test Date/Time S <br /> •4.'1LT.•SANITATION PERMIT - <br /> } 7v_ <br /> 'Job-•Aiidress/Location Z4675"S V41 d STo - <br /> .Owner- AtJS f�r4[-.�$�Z4.� Address < <br /> O'SEPTIC TANK ❑ G�ESSPOOL 0TEACHING FIELD ❑ SEEPAGE PIT '>r❑-PACKAGE PLANT` {� <br /> G �1:'FERMANENT ❑ TEMPORARY 13-NEW ❑ REPAIR ❑;OTHER <br /> I' <br /> 13 CHEMICAL TOILETS For'July 1,-June 30, 19 W 1 <br /> ,. <br /> Pe Construction —•• Disposal Site. r' <br /> No.of Units Equipment Storage/Cleaning Location(s).. ` - - } • ( <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1,-June`-30, 19 t �:, -i <br /> t ?. . Where Certified. <br /> Operator Name j y ' <br /> Plant Location ' + <br /> 'Plant Capacity i No. Units Served <br /> k-4 <br /> '7. 11 LAUNDRY For'July 1,-June 30,19 - <br /> ❑ More Than 1,000 S Ft. <br /> SIZE: ❑ Less Than.1,000 Sq.Ft., q- _ I• <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. - + <br /> I hereby certify that I have prepared this applicati and t the work will be done in acCoAdance wtth.San Jquin County \ <br /> ordinances,state laws, r l andr ulation the n oaqu• Local Health Difthb 1.� —•� ��. <br /> i ' •� -s i <br /> 'APPLICANT'S SIGNATURE r -•' t :F <br /> { t <br /> I i FOR DEPARTMENT USE ONLY <br /> }sx. <br /> I Fee IS Due:13-.ANNUALLY ❑ PER UNIT: ❑ PER SITE ❑EACH ❑ January t 8 Received By January 31 :❑Jury 1$Received By July$1 <br /> - {� j ' REMIT s � <br /> BASE - EXPLANATION BILLING REMITTANCE $ t., AMOUNT DUE a% CHECKED y <br /> DATE DATE REMITTED' ;t AMOUNT <br /> FEE S 1 � ` � i • G�t_��� I <br /> LESS <br /> + PRORATION t <br /> PLUS ' <br /> ' PENALTY <br /> OTHER t <br /> 4 <br /> All <br /> Received by Date Receipt No. v Permit No. Issuance Date Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.OH TO A o.hoc 2008 STOCKTON,CA OS201 <br /> ////////JJ �1, <br />