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Applications Will'Be Processed When Submitted Properly Completed. BeSureTo SignTneApplication. <br /> APPLICATION <br /> 11 (For Non-Transferable, Revocable, and Suspendable) $EPTAGE it <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District � � <br /> OF Business Name (DBA) SW �^�saG- �a"j Address z5.� <br /> z Owner } Address <br /> Firm Partners, Addresses and Telephone Nulmbers <br /> a46 Telephone No. —46 - 3 47� - Emergency Telephone No. <br /> -J Contractor Licence No. S S-3 <br /> j•; <br /> Applicants Name (Print) FLc1 t✓�'d Title !�' —ye'� Date <br /> Please check Applicable Category (1-7),and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <br /> For July 1, June 30, 19 Disposal Sites ? <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc�se Renewal No. 10 <br /> Capacity Gal.,Weights &Measures No.. <br /> Equipment Parking Address I <br /> 9 <br /> 2. ❑ PUMPER YARD 1 I <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 i Test Date/Time <br /> 4. 9 SANITATION PERMIT ll <br /> Job Address/Location p3 S !nC�c <br /> Owner lNl✓L�.La -2.an/Sf�27� Address d2G�S IvIA�IN� Gi L'� <br /> ❑ SEPTIC TANK ❑ CESSPOOL it LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> 14 PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Loeation(s) � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Where Certified Q <br /> Operator Name • <br /> Plant Location ; <br /> I Plant Capacity No. Units Served { <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 / <br /> It SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. I <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i!. <br /> I hereby certify that I have prepared this application and that the work will be done in a tajnce with Sa uin k + ti <br /> ordinances, state laws, and �regulathe San Joaquin Local Health Dist «, <br /> APPLICANT'S SIGNATURE X L <br /> � n <br /> :i FOR DEPARTMENT USE ONLY <br /> } <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 ecei'ved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I <br /> y BILLING REMITTANC °�' $ AMOUNT DUE CHECKED <br /> it BASE 'iE EXPLANATION DATE DAT REMITTED AMOUNT <br /> li 's <br /> { <br /> FEE O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i! <br /> OTHER <br /> Issu nce ale M <br /> Received by Date - Receipt No L Permit No. ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O-.Box 2009 STOCKTON,CA 95201 <br /> 46w,� *-ae-S70 a� 3 <br />