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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> s � APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL, HEALTH PERMIT SE:PTAGE <br /> LIQUID WASTE <br /> Application inhere y ma a tgc ryoq btfS�nss in the jurisdictional area of the a� a in L I Health District <br /> y Business Name (DBA) r �j AddressS ` ",2/ 144. zV p�%& <br /> 01 <br /> a Owner_ Q Address �" ' e <br /> J Firm Partners, Addresses and lephone Numbers <br /> aBusiness Telephone No. ��73AC38`3 Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) r cl/l�A1i Title <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. Llc::nse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 f 11 <br /> No. of Vehicles Stored V <br /> e <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 ovation Test Date/Time r <br /> 4. SANITATION PERMIT <br /> Job Address/Location S W A J " nj <br /> Owner Pn IWbAn Address07 <br /> SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT 1 I l <br /> ^PERMANENT ❑ TEPFPORARY NEW ❑ 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 /> 6. ❑ 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. ❑ 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 /> I 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, a ules and reg tiorys 0�fhe aquir�Local Health District. <br /> APPLICANT'S SIGNATURE X ____r_ 14 <br /> APPLICANT'S , <br /> FOR DEPARTM7�� <br /> U LY <br /> Fee Is Due: El ANNUALLY Cl PER UNIT PER SITE ❑ EACHJanuary 1 8 Received By January 31 C1July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �y AMOUNT <br /> FEEj� cam' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> kF <br /> OTHER <br /> 1 -7 9 ."'$ <br /> AJ Li <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Deliv ed <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 95201q <br /> W � <br />