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..-..l <br /> Applications;W111 Be Processed When Submitted ProperlyCompleted. P <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> i ENVIRONMENTAL HEALTH PERMIT SI PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> `Business Name (DBA)_ 60[ Da"Id S"e it'e eV Address <br /> i Owner T• R*'r DQUald Address <br /> z <br /> J.Firm Partners, Addresses and Telephone Numbers "" :. <br /> a Business Telephone No. 1"� k Emergency Telephone No. <br /> Contractor licence No. 3oDate <br /> + « : Title 7 <br /> L Applicants Name (Print) � <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR-EACH-VEHICLE) L <br /> For July 1, Juney30 19 - '' Disposal Sites � � <br /> Description(Make/Yr., Color) J. <br /> CAL. License Renewal No. <br /> Serial No. <br /> CAL. License No. <br /> _ <br /> Capacity �� Gal.,Weights & Measures No. } k � <br /> Equipment Parking Address- <br /> 2. <br /> Y. <br /> 2. ❑ PUMPER YARD 7 <br /> For July 1, June 30, 19 - <br /> No. of Vehicles Storedp<_ <br /> No. of Chemical Toilets Stored <br /> f 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name L - <br /> I� Test,Date/Time L <br /> Test Location �- <br /> 4. ❑ SANITATION PERMIT <br /> Job AddresslLocation �. <br /> Owner IrLo <br /> SEPTIC TANK ElCESSPO5L LEACHING FIE ❑ EPAGE PIT <br /> ACKAGE PLANT <br /> 11 PERMANENT . ❑ TEMPORARY NEW ❑4REPAIR— 0-OTHER <br /> -5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> I _ Disposal;Site <br /> Type Construction:'_ _ <br /> No. of Units - i�' Equ pment Storage/Cleaning Location(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30719 Where Certified <br /> r Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> r <br /> 7, 11 LAUNDRY For July 1, -June 30, 19 �f <br /> SIZE: ❑ Less Than-1,000 Sq+Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> ! hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and,rulesand regulations of San Joaquin LacHeal rDistrict. <br /> I rf <br /> APPLICANT'S SIGNATUREX <br /> . <br /> i .FOR DEPARTMENT USE ONLY - <br /> s Fee Is Due: 12 ANNUALLY:' ❑ PER UNIT ❑ PER 51TE- E3EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Receiv REMITuIy 31 <br /> li BILLING REMSTTANCE $ AMOUNT DUE, CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED 'C:. AMOUNT <br /> FEE <br /> LESS <br /> PRORATIDN IIE <br /> r <br /> PLUS g a% <br /> PENALTY <br /> OTHER I _ 'k ;C - <br /> OTHER - <br /> If Iq ` <br /> Received by <br /> D_at Receipt No- rniit No: IsSuance'Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7601 E.HAZE470N AVE.,P.O.Sox 2009STOCKTON,CA 95201 <br /> a ,�p <br /> 4 ..vw_.. <br />