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Applications Will Be Processed When SuAPPLICATION - -L <br /> � y (For Non-Transferable,Revocable, and Suspendable) SEQTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> L1QU10 WASTE <br /> Application i here y m to carry o bus' s in t e jurisdictional area of the San Joa in Local Health District ?(f) p <br /> Address !( <br /> wBusiness Name (DBA) Address ' <br /> a Owner�liCT <br /> mbers <br /> N <br /> .Firm Partners, Addresses and Telephone �IEmergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Title ate <br /> Applicants Name (Print) <br /> �-7) and Fill in the Required Information <br /> Please check Applicable Category ( 'a' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <br /> For July 1, June 30, 19 <br /> Disposal Sites ' <br /> {Make/Yr., Color) CAL Lic:.n5o Renewal No. <br /> Description <br /> CAL. License No. 41 ) �'y <br /> Serial No. A �- �hts'& Measures No. ' + <br /> Capacity al.;Weig <br /> Equipment Parking Add rress. <br /> s <br /> 2. ❑ PUMPER YARD „1 <br /> For July 1 �"I*Ju2-1 9 � <br /> 1 k E <br /> R <br /> No. of Vehicles Stored' .' <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. S <br /> R.S.or R.C.E.Name <br /> Test Date/Time <br /> Test Location € <br /> Q SANITATION PERMIT t <br /> 1 a <br /> Job Address/ ocation <br /> Address <br /> Owner u ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑�PACKAGE`PL-ANT ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ NEW ❑ REPAIR ❑ OTHER, <br /> ❑ PERM6EN7 ❑ TEMPORA <br /> June 30, 19 Ff . <br /> 5. ❑ CHEMICAL TOILETS For July 1, Disposal Site ` <br /> I Type Construction <br /> No. of Unfits Equipment Storage/Cleaning Location(s) � <br /> F . <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Wff here Certified <br /> P Operator Name '~ <br /> Plant Location No. Units Served <br /> ' Plant Cap city . 0 <br /> 3 <br /> T. 114 L&A�U-NDRY For July 1, - lune 30, i9 <br /> Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> SIZE:; <br /> I ❑ DRYS-CLEANING, Chemicals Used/Amount/Mo. <br /> �'eP® 7 ���.�sf ' d,�Co t I ,mac ► <br /> I .AL3 z''T i. ►s .IR F <br /> ° t*� lon and that the work III be done in-accord ait an Joaquin County + <br /> sy <br /> I I hereby certify that I have pre loth app <br /> ordinances, state laws, an l an gul of the San Joaquin L al Health District. 1 V IF <br /> s APPLICAN-T'S SI,GNATU 1( rt <br /> T; T• <br /> FOR,DEP,ARTMENT USEEO.-.LY <br /> Bary 1 &Received By January 31 ❑ J' Y�� Received By July 31 <br /> REMIT <br /> Fee IS Due, ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH TTANCE AMOUNT DUE CHECKED <br /> ' BILLING <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> x <br /> FEELES S <br /> ! • <br /> PRORATION <br /> i PLU - <br /> PENAiTY <br /> k OTHER <br /> A <br /> i OTHER <br /> i <br /> it �. ,O <br /> _fib <br /> ` Mailed Delivered <br /> " <br /> t <br /> Permit No. 455u8nCB Date tot <br /> h Date ReceipS No. - $ <br /> _ Received 6y 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON, <br /> 1� APPLICANT—RETURN ALL COPIES o ENWRONMENTAL HEALTH -r/SERVICES <br />