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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> Z ENVIRONMENTAL HEALTH PERMIT "`' "A`G" Q <br /> LIQUID WASTE ..51 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Q. 44�VR isW 0'0' sc'Al s Address Pe' 6'X / r'S- s`TK-✓ 9S3e�/ <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 5p6e,7 Emergency Telephone No. <br /> Contractor Licence No. 3�3 <br /> L Applicants Name (Print) Title Date L"7--'7`Oo <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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. _M SANITATION PERMIT <br /> Job Address/Location VS-9e S, #Wp 9!2 S'7VC.11-710»J <br /> Owner -P-64774 -5'MC&7?,') /<l//!?.9,r/6 jW�/A Ty ddress 514_0�4' <br /> ❑ SEPTIC TANK ❑ CESSPOOL J& LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY ❑ NEW 2q 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <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., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this applicatio that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations�the a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑. ANNUALLY ❑ PER UNIT Ig PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> It DATE DATE REMITTED <br /> AMOUNT <br /> FEE Si 0/_/� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / z 7, Z <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Pe it No. Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Box 2009 STOC ON,CA 5201 <br />