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f Applications WIII;Be Processed When Submitted Properly Completed. Be Sure To Sign The Appilcation. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> v ENVIRONMENTAL HEALTH PERMIT _ §EPTAGE <br /> LIQUID WASTE :. r. <br /> ff <br /> v Application is hereby made to carry on business in-the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) PP-4. PARRISN Sa�,rJS Address <br /> i Owner <br /> 4 74 -0/ <br /> i i <br /> Address_. �o PoX �5j�d -ST,�.�J <br /> J Firm Partners, Addresses and Telephone'Numbers <br /> CL <br /> Business Telephone No. ��" 96,97 Emergency Telephone No. <br /> Contractor Licence No. <br /> — <br /> L Applicants Name (Print) Le ao z Title j Sr/n1 A 7a.%1_ Date -3 - 7 9, \ <br /> Please check Applicable Category (1-7) and Fllfin 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 /> i Serial No. CAL. License No. CAL. Licznse 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 /> 1 <br /> R.S. or R.C.E. !Name R.S. or R.C.E. No. <br />( Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location /l/7 9 S.1*7C g/A.;4-4_e . MAA) <br /> Owner WA I.L-yW N I Address ZEE <br /> SEPTIC TANK ❑ CESSPOOL I.X LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAINT <br /> r ❑ PERMANENT ❑ TEMPORARY } ❑ NEW REPAIR ❑ OTHER <br /> 4 5. ❑ CHEMICAL TOILETS. For July 1, June 30, 19 <br /> Type Construction Disposal Site <br /> I' No. of Units <br /> Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July-1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location r <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 the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules nd regulations of the n Jo uin Local Health District. P <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑.July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT _ <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> (I DATE DATE REMITTED <br /> AMOUNT --_ <br /> FEE <br /> LESS <br /> PRORATION ?<}. <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER s y1* <br />'- Received by Date f Receipt No. Permit No. Issu nce Date Mailed Deliver <br /> r <br /> APPLICANT=RETURN ALL CQPIES;TO:;+:,;,ENVtRONMENTAL HEALTH'PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON;C 5 _. <br /> t <br />