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1 AppiiCallons vitro Iset-rocessea vvnen auvmtnrUrruNcny a,,WmP­a... ..c .+...� ..+ ...y.. ...�--rr•---•• <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) 5;1'l'ACF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic on Is eb made to car on busine n the jurisdictional area of th an Joaquin Local Hoalltth Dis ricl r <br /> ( ) �I �j,:f <br /> Business Name D8A _. _Owner----- __ _ _ Address <br /> Firm Partners, Addresses and Te qMone N bers .-�} --- <br /> Business Telephone No. 'ry Emergency Telephone No._ <br /> Contractor Licence No. <br /> Applicants Name (Print) �Jr `� �� _. T.itle !1!�"''L` bate ' <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 /> A.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Te t L cation Test Date/Time , <br /> 4. SANITATION PERMIT <br /> Job Address/Location } C' '? -+' — <br /> Owner 1=�L4r'� � - Addrestts���� �l — <br /> ❑ SEPTIC TANK 11 CESSPOOL' KLEACHING FIELD tKSEEPAGE PIT ❑ PACKAGE PLANT <br /> CI(PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ y <br /> Type Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Locations) _ <br /> I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where'Certifled <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., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> tf, <br /> I hereby Certify that I have prepared this application and that.the work will be done in accordance with San Joaquinrouilty <br /> ordinances, state laws,and rules and reg lationb�}the an Joa uin Local Health District. <br /> APPLICANT'S SIGNATURE X - -- -•� ��r'f�"' i� 4 , <br /> FOR DEPARTMENT USE ONLY 'r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Heteived By January 31 ❑ July t a Received By July 31 <br /> " REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S.' AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - <br /> _� <br /> LESS / <br /> PRORATION <br /> PLUS <br /> PENALTY u' ' <br /> OTHER <br /> OTHER. <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE:,PA.Box 2DO9 STOCKTON,CA 9520 <br />