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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> s APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SE�TAG� <br /> LIQUID WASTE <br /> Applicat is here ode to carry on business in the jurisdictional area of the San Joaquin Local Health District ] ' <br /> rBusinessName (DBA) d70aO�i� S' �l1l�� Address /ids S ��GT - C7' ! <br /> aOwnerAddressT,7as <br /> Firm Partners, Addresses and Telephone Numbers --5 <br /> aBusiness Telephone No. ., ,�—Zfn' Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) Title L� Date g Sy <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) F <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. f CAL. License No, CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD j� t <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.G.E. Name R.S. or R.C.E. No. , <br /> Test Location Test Date/Time s <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER 574VIVtO <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <br /> Operator Name ° t Where Certified <br /> Plant Location <br /> Plant Capacity t No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June'30, 19 <br /> At <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit J In County <br /> ordinances, state law r s and regulatio of the Sa oaquin Local Health District. $1 4 <br /> e <br /> APPLICANT'S SIGNATURE X , J CO <br /> li FOR DEPARTMENT USE ONLY <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT PER SITE . ❑ EACH ❑ January.I &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT 4 <br /> BILLING REMITTANCE $ <br /> BASE a EXPLANATION DAMOUNT DUE. CHECKED <br /> ATE DATE REMITTED <br /> AMOUNTr <br /> EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ! <br /> OTHER II t <br /> Received by Date 1 Receipt No. Permit No, k4ivanbe Date Mailed alive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STO TON,C 95201 - <br /> : <br />