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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> =_%'= APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) r . $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of-the San Joaquin Local Health District, <br /> NBusiness Name (DBA) Address ._ z o <br /> z Owner f3b3a �€ L�V_INS Address 7. 8 7 �b/ T/Nd e./ <br /> a wv. _ - : <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. e, Emergency Telephone No: <br /> -Contractor Licence No. - 9 <br /> Applicants Name (Print) r LE C'?^- T 0 Title Date S r <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER"VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />`For�July 1� June 30, 19 = ' - Disposal Sites t <br /> Description(Make/Yr., Color) t <br /> erial No. CAL. License No. CAL. License Renewal No. Y <br /> Capacity Gal., Weights &Measures No. - <br /> Equipinent,Parking Address _ <br /> 2. ❑ PUMPER YARD t ) <br /> For July 1; June 30, 19 <br /> No. of Vehicles Stored , <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> R.S. or R.C.E. Name R.S. or R.C.£:No. <br /> Test Location Test Date/Time <br /> 4. ® SANITATION PERMIT �i �/] . <br /> Job Address/Locations 8 / fKAT�/"�� � �� �'" - f" <br /> Owner - Jq 04 F- 7!7]F— '"_ 6L4&6Add,ess 7 8$ 7 <br /> ❑ SEPTIC TANK IJ CESSPOOL r ❑ LEACHING_ FIELD IZ SEEPAGE PIT ❑ PACKAGE PLANT o0 <br /> ❑ PERMANENT ❑ TEMPORARY ; ❑ NEW ❑ REPAIR_ ❑ OTHER _J <br /> -5. ❑ CHEMICAL TOILETS For July 1,"June 30, 19 r <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT` For-July 1, -June 30, 19 <br /> Operator Name #s r T - � 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 /> 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 re ulations of the San Joaquin Local Health Di ict. <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH_ ❑ January'l &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ - - _ <br /> EASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE <br /> REMITTED AMOUNT <br /> d <br /> FEE ` <br /> LESS i <br /> PRORATION <br /> j PLUS A <br /> PENALTY <br /> OTHER <br /> OTHER 4 L - <br /> Ns 7 <br /> Received by ale Receipt No. Permit No Issuance Date Mailed DIalivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTPERMIT/SERVICES 11601 E.RAZELTON AVE.,P.O.Box 2009 579GKTON,CA 95201 <br /> H i <br />