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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION C-91 <br /> (for Non-Transferable,Revocable,and Suspendable) y" '�•"� <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAL a <br /> LIQUID WASTE O 17_ Z3t7—IS <br /> Applicatio is r me to on b 'Hess in the jurisdictional area of the Jog in Local HejUh District <br /> F Business me(DBA) <br /> Owner—Pelf f Address <br /> Firm Partners,Addresses nd Telephone Numbers <br /> Business Telephone No. -3713-15 _ Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> 1 Applicants Name (Print) £ Title Date <br /> Please check Applicable dalegory(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, .lune 30, 19 Disposal Sites <br /> Description(MakeNr.,Color) <br /> Serial No. CAL.License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights S Measures No. <br /> i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30. 19 <br /> No.of Vehicles Stored <br /> r <br /> No.of Chemical Toilets Stored ,s <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location Test Dale/Time <br /> 4. 0 SANITATION PEIT <br /> Job Add s/Locaticn E <br /> Owner Address 174 <br /> 0-9EPTiC TANK ❑ CESSPOOL eLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT .��++ "1 . <br /> ERMANENT ❑ TEMPORARY W-NEW ❑ REPAIR ErOTHER ! '1 <br /> s s. ❑ CHEMICAL TOILETS For July 1.-June 30, 19 1�' <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ 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.F1.. ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING.Chemicals Used/Amount/Mo. <br /> I hereby certify that I have p r thisJ <br /> ' a that the work will be done in accordance with San Joaquin County • <br /> ordinances,state laws,and nd r iguth n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE OULN <br /> Fee Is Duet 0 ANNUALLY Q PER UNIT 9 PER SITE C3EACH ❑ 8 1 d R%mived By January 31 ❑July 1 A RMetr@d 6y Juty 31 <br /> AEMIT <br /> BASE EXPLANATIONgOATE E E AEMtTTEO A4IOUNT DUE CHECKED <br /> AMOUNT <br /> FEE y� <br /> LlrSS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R PIyea by Date Ravk;pt No. Pefmlt NO- �PPLICANT—REW <br /> TURN ALL COPIES M ENYIROW rILL HEALTH PERP ISEAVICEE 7 E.'muance � <br /> %4=TON <br /> MaMd <br /> A .Dot SEOe N.STOC "ain <br /> --- - -- -fie- (f�� A /_ 3 `euv a <br />