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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicatiom <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />di Qa is herebojL4e to C nb I sin theliurisdictional area of the 8 1 Jia I L c;al Health trict <br />— arst"Y"TT., e_1 2;�� <br />SEPT AGE <br />Business N=e (DBA) -4-1-106 z <br />Owner - - ___ - <br />Address <br />Firm Partners, Addresses and Telephone Numbers 7MfFrC <br />Business Telephone No. ...... .... Emergency Telephone No. _1Jr— . .... <br />Contractor Licence Nc..,,� <br />?A <br />Title <br />Applicants Mame (Print) . ...... <br />Please check Applicable Category (1-1) and Fill In the Required Information <br />1, C1 PUMPER VEHICLE PERMIT AEG ISTRATION (FOR EACH VEHICLE) <br />Fo r July 1. __ ,,, ., _ . .... . June 30. 19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No, CAL. License No. ..... ..................... CAL. Lie' I No. <br />License RentWO <br />Capacity Gal,, Weights & Measures No. ............. <br />Equipment Parking Address <br />2, 13 PUMPER YARD a <br />For July 1,_ June 30, 19 <br />No. of Veniclp.s Slored <br />No, of Chemical Toilets Stored <br />3. 0 PERCOLATION TEST <br />R.S. or A.C.E. Name .... .......... .... ......... . R.S. or R.C.E. No. ..... . . ...... .. <br />Test Location __ . ...... Test Date/Time_.-, <br />4. C1 SANITATION PERMIT <br />Job Address! cation.., <br />Address <br />S-A 2? <br />FjPACKAGE PLANT <br />' <br />SEPTIC TANK ❑ CESSPOOL &-LEACHING rlELD ffSEEPAGE PIT <br />Q/PERMANENT EI TEMPORARY 0 NEW OTHER <br />CHEMICAL TOILETS For July 1, - June 30, 19 ................. <br />construction —.,. . . .......... ................... . .... <br />Disposal Site ..... ...... .... . ..... .u..._,__._..._.._..._.._.............__. <br />No, of Units . .. . . ..... ____ Equipment StorageJClearing bocation(s) <br />6. 0 PACKAGE TREATMENT PLANT For July 1. - June 30, 19 <br />Operator Name . . ... . ..................... .. ..... . ... ....... ------- Where Certified . ....... <br />Plant Location ­­ ­­­ _'. .--- - - .--+ <br />Plant Capacity ....... ..... No. Units Served . <br />7. 13 LAUNDRY For July 1, - June 30, 19 <br />SIZE 0 Less Than 1,000 Sq Ft., 0 More Than 1,000 Sq. Ft, <br />C3 DRY CLEANING, Chemicals Used/Amount/Mo. . .. . ...... <br />I hereby certify that I have prepared this applicationAnd that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules 4o"Mations45��Otiof <br />-g000squin Local Health District. <br />APPLICANT'S SIGNATURE X <br />Fee Is Due! EI <br />FEE <br />LESS <br />!fIgRATION <br />PLUS <br />PFNAI Ty <br />OTHER <br />FOR DEPARTMENT USE ONLY <br />r_1 Il . 0 <br />SASE EXPLANATIONT <br />BILLING i <br />DATE <br />REMITTANCE <br />$ <br />EMITTED <br />REMITTED <br />AMOI.INT DUE <br />... ....... <br />. . ......... <br />CHECKED <br />OTHER <br />rt <br />PeiMd No <br />ApLC,*T_jWTuAW ALL COPIES TO! 199VIRONIASWAL HEALTH PERMIT/SERVICES isal E. HAZELTON AVE.. P.O.!3*x 22L* STOCXToN-r. A 96201 <br />