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•Applications Will Be Processed When SubmittedProperly GOmPrG«v• - <br /> APPLICATION <br /> (For Non-Transierabie,Revocable,and SusRMIT te) $EpTAGE ; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> — LIQUID WASTE :` <br /> ea of the SV <br /> Application is hereby made to crryon business in the jurisdictional� Aa�dres� .�a�-Paquin Local Health District <br /> a <br /> .SP e e <br /> y Business Name (DBA) Address <br /> r7 <br /> aOwner - <br /> J Firm Partners, Addresses and Telephon eNu rs Emergency Telephone No. <br /> OIL' Business Telephone No. % 7 _-� <br /> �Contractor Licence No. Title /F s c �"�` Date <br /> r <br /> LApplicants Name (Print) 1-7 and.Filln' a Required Information <br /> Applicable Category ( )- <br /> Please check App TION (FOR EACH VEHICLE) .. <br /> ❑ PUMPER VEHICLE PERMIT REGIS, <br /> --June 3019 Disposal Sites <br /> rx <br /> For July 1, — - <br /> Description r mor CAL�.License-No� <br /> (Make/Yn�-- y_ CAL. Lic-,1se Renewal No. <br /> Serial No. <br /> ,...may <br /> Gal_,Wds19 ts:,8Measures No. <br /> Capacity <br /> . , <br /> Equipment Parkg Address t <br /> t 2. ❑ PUMPER YARD <br /> � s <br /> No:of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S.or R.G.E.No. <br /> R.S. or R.C.E.Name F Test Date/Time <br /> r_ <br /> t Test Location <br /> 4. ❑ SANITATION PERMIT�� <br /> Job Address/Location ,�- r /,, Address 7 <br /> Owner <br /> �76.iewr +� C3 PACKAGE PLANT <br /> 11 SEPTIC TANK ❑ CESSPOOL NEA1NCHING FIELD ❑ REPAIR E PIT ❑ OTHER _ <br /> 13 PERMANENT 11 TEMPORARY <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 19 � - � � <br /> Disposal Site <br /> Type Construction ._Z.' " <br /> Equipment Sn <br /> Storage/Cleaning Locatios) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> I Operator Name A r <br /> Plant Location No. Units Served <br /> I Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-, 11 More Than 1,000 5q. Ft. 4Z. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <br /> ° {nl ty <br /> } I hereby certify that I have prepared this application and that the work will be done in accordance with l _ <br /> ordinances, state laws, a d rules and egulations oft San Joaquin Local Health District: <br /> s J <br /> APPLICANT'S SIGNATURE X �. <br /> FOR DEPARTMENT..USE.ONLY— .. <br /> Jul 1 &Received By July 31. <br /> REMIT <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Receive$d By January 31 ❑ y CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT DUE AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> I FEE `►r �' ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> t PENALTY <br /> F <br /> OTHER <br /> OTHER ' <br /> la< 3d <br /> Receipt Na. - Permit No. <br /> Issuance Date Mailed Delivered <br /> f Received by Date - - . 1601 E.HAZELT <br /> APPLICANT—RETURN ALL COPIES <br /> ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> - _ TO:' ENVIRONMENTAL HEALTH PERMiTlSERYIGES <br />