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rnitted Properly <br /> - I Applications Will Be Processed When Sub�PPL�CAT�ONPlerea.K1= <br /> I: (For Non-Transferable, Revocable,and Suspendable) ScPTAGE .,,. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> II LIQUID WASTE Y <br /> •U fq Ve , I <br /> gpplicatio 's here made to car on b si ess in the jurisdictional area of the 5a�J'�oa�uin Local Health District <br /> gfjo .51t2 Address <br /> Business N�a p (DBA) Address s " <br /> aOwner 1F ' <br /> l L).Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. <br /> x 2`4 Date V f <br /> Contractor�Licence No. t rYil Title <br /> L ApplicantsI Applicable Name (Print) tion <br /> Please check cable Category�(11-7)and Fill in the Required Informal <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 1�� June 30, 19 _,�� Disposal Sites <br /> For July 1, . <br /> Description(Make/Yr lColor) CAL. Lic,:se Renewal No. <br /> Serial 110 <br /> I� CAL. License No. <br /> Capacity I Gal.,Weights & Measures No. <br /> I. Equipment Parking Address �M <br /> 2. ❑ PL PERYARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored IIS, <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or 4C.E. Name Test Date/Time <br /> IM N <br /> Test Location <br /> q. ❑ SANITATION PER <br /> Job Address/Location Address <br /> Owner �� �' LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL ❑ REPAIR ❑ OTHER r <br /> ❑ PERMANENT ❑ TEMPORARY NEW <br /> S. 11 CHEMICAL TOILETS For July 1,-June 30, 19 ' <br /> ��. Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Locations) . <br /> 6. 11 PACKAGE TREATMENT For July 1, -June 30, 19 Where Certified `. <br /> j Operator Name ` <br /> Plant Location No. Units Served <br /> Plant Capacity R <br /> 7. ❑ LAUNDRY For July 1,: June 30, 19 <br /> SIZE: Ili ❑ Less Than 1,400 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY,CLEANING, Chemicals Used/Amount/Mo. <br /> t I <br /> . I <br /> licatioh and that the work will be done in accordance with San Joaquin County <br /> I 1 hereby certify that I have prepared this app <br /> 1 ; I ordinances, state laws, an es and regulations o�3e San Jo uin Local Health District, <br /> APPLICANT'S SIGNATURE X, <br /> CfYyi � l\.� <br /> I li <br /> IONLY <br /> FOR DEPARTMENT USE <br /> EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE REMITTANCE $ AMOUNT DUE CHECKED DATE <br /> BASE' EXPLANATION BDATE REMITTED AMOUNT <br /> iM <br /> ! FEE <br /> t I LESS <br /> F I PRORATION y <br /> PLUS ,II <br /> PENALTY III <br /> OTHER II <br /> t I OTHER II <br /> lD <br /> 4 —7-1 <br /> Q Issuance Date Mailed Deliv ed ; <br /> Date Receipt No- Permit No. <br /> Received by ,��; 1661 E.HAZEL78N AVE.,P.O.Box 200 TO TON,C 85201 Q <br /> APPLICANT—RETURN ALL COPIES TO'. ENVIRONMENTAL HEALTH PERMIT/SERVICES CC��/� <br />