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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S�PTAGE 4 <br /> k. LIQUID WASTE <br /> 3 , <br /> Appl icatiop.1 hereby tmade o car,� n business in the jurisdictional area of the San Joaquin Local Health District <br /> y <br /> Business Na (DBA) J p ul est! �chS ,P,e_ Sp M.,eC_� Address �.�3 ��'�' �G� <br /> z Owner 10.3 x1 >�i�us� Address Z�'A_ �A&�� <br /> 1 Firm Partners, Addresses and Telephone Numbers 14 <br /> aBusiness Telephone No. Al 7 Emergency Telephone No. (E7y""���[� Q <br /> Contractor Licence No. c� <br /> L Applicants Name (Print) . Title �� /�?^Qs• Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d} <br /> For July 1, June 30, 19 t� Disposal Sites r t <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. 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. Cl-,SANITATION PERMIT _ <br /> Job Address/Location +,U) _ <br /> Owner J�l bw a&,, 0-Q.FrI Address XlS � I <br /> Lff SEPTIC TANK ❑ CESSPOOL h LEACHING FIELD X SEEPAGE PIT ❑ PA KAGE PLANT h <br /> ❑ PERMANENT ❑ TEMPORARY QII` NEW ❑ REPAIR ❑ OTHER v <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of UriitS Equipment Storage/Cleaning Locations) j. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - Where Certified +L <br /> Plant Location <br /> Plant Capacity No. Units Served # <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- t <br /> SIZE: ❑ Less Than 1;000,Sq. Ft.; ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a <br /> I 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, a rules and reCiulation of the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r� <br /> { FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received ByJanuary 31 ❑ Juty 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT i <br /> BASE - EXPLANATION AMOUNT DUE CHECKED <br /> PATE GATE REMITTED G <br /> ;} AMOUNT <br /> FEE 4J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER { <br /> k� <br /> OTHER <br /> ds C� <br /> Received by Date - Receipt No. Permit No. fssuande Date Mailed Deliv ed - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.;P.O.Box 2009 STO TON,CA 95201 3 <br />