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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> s APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 5Ei'TAGE <br /> r <br /> LIQUID WASTE <br /> Applicati hereby mde to caX4 on business in the jurisdictional area of the San Joaquin Local Health District <br /> OBusiness Na�,e (DBA) <br /> t 1 �PS k 12 L Address ISO I3:-,Ti ter.: AV <br /> , CA <br /> � <br /> a Owner l+'►'1 l ✓�&GIJC Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �� `� �� Emergency Telephone No. — <br /> Contractor Licence No._?LLA o7) V <br /> LApplicants,Name (Print) 1 ion C xkm G1lie Title Date <br /> Please check Applicable Category (1-7)and fill in the Required Information <br /> 1. ❑ PUMP, <br /> ER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> For July 1, >*- -fi June 30, 19 Disposal Sites <br /> i{ Description(Make/Yr., Color) <br /> 1 Serial No. CAL. License No. CAL. License Renewal No. ' <br /> t <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 /> I Test Location Test Date/Time <br /> I 4. ❑ SANITATION PERMIT <br /> Job Address/Location b I ��a te-cls C +f*, <br /> i� :. <br /> Owner �}eQA Address 3A"') - - <br /> 91 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �. <br /> ❑ PERMANENT ❑ TEMPORARY F1 NEW ❑ REPAIR ❑ OTHER <br /> r 5. © CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> ` No, of Units Equipment Storage/Cleaning Location(s) <br /> I <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 /> 1 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, an�wles and regulations of the 5a oaquin Local Wealth District. <br /> rID <br /> APPLICANT'S SIGNATURE ` <br /> r <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> + Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S �7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a� <br /> Received by Dale Receipt No. Permit 1.0 Issuance Date Mailed Deliveref <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,PlO.Box 2009 STOCK N,CA 95201 <br />