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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) $EPTAGE <br /> O ENVIRONMENTAL HEALTH PERMIT <br /> LIQIII0 WASTE <br /> Application is hereby made to carry on busine s in the jurisdictional area of the an Joaquin Local Healt is rict <br /> p e Address" 13� <br /> rBusiness Name (DBA) D. <br /> 4. / <br /> r Address <br /> a Owner <br /> u– Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. — g� Emergency Telephone No. 1 <br /> Contractor Licence No. ZT <br /> LApplicants Name (Print) <br /> TitleDate <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 /> I 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 /> R.S. or R.C.E. Name R.S. or R.0 E. No. <br />: <br /> Test Loca n Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location /4444 °• £sGS1.eg_,D <br /> Owner 1113El11er �- � Address <br /> 7 <br /> L�.�SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT 4 <br /> EJ PERMANENT ❑ TEMPORARY ❑ NEW 0 REPAIR ❑ OTHER <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 /> 66. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name y <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C3,More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo.. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and r lations he Sa aqu Local Health District. <br /> I APPLICANT'S SIGNATURE <br /> .� DZ <br /> FOR DEPARTMENT USE ONLY <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By EM1Tuly 31 <br /> f - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED` AMOUNT <br /> FEE 14 Ll '5 <br /> I LESS k <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date ., Receipt No. mit No, ssuan Date Mailed - Delivered. <br /> Per <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON A � 09 STO 95261 <br />