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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> t APPLICATION <br /> - <br /> (Far Non-Transferable, Redocable, and Suspendable) <br /> -. ENVIRONMENTAL HEALTH PERMIT SPAGE <br /> LIQUID WASTE Q <br /> Application is hereby made to carry on busl ss in the jurisdictional area of the San Joaquin Local Health District r <br /> HBusiness Name (DBA) Address �6 <br /> i Owner Address <br /> C <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. & — G Emergency Telephone No. <br /> Contractor Licence No. <br /> dt Applicants Name (Print) Title �57ii�1.Q'r"a.@ Date 'x-57' <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. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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.E. No. <br /> Test Location Test Date/Time <br /> 4. A SANITATION PERMIT � <br /> Job Address/Location <br /> Owner— L LA M Address N <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD C1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW P REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 T <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 C <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> s <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 an work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of th n Joaqui Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EAGH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> +/ <br /> FEE <br /> LESS <br /> PRORATION - - - <br /> PLUS - -PENALTY" <br /> OTHER <br /> OTHER <br /> =19=APO ` 1 7 <br /> Received by Date Receipt No. Per No. issuance Dat Mailed Del' eyed <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PE IT�ICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5 CKTON CA$6201 <br /> 7�CZ/// i <br /> 7 1�1 <br />