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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. \ <br /> APPLICATION ,S <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SE:PTAGE I <br /> ._ LIQUID WASTE � <br /> Application 's ereb made to c on bu ss i the jurisdictional area of the San Joaquin Local H aith�Istrict <br /> ,�Business Na (DBA) f r �h��s Address �[��,if - <br /> aOwner— utrSan of A dre <br /> Firm Partners, Addresses and Telepho a Numbers ^� /`,'>`c as y <br /> CL <br /> hone No.Business Telephone � ,�7&�� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) f;lTitle 11 tQ 1n a a pr Date <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 \O <br /> Description (Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. Liccnse 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. TKSANITATION PERMIT <br /> Job Address/Location I Q 3& s -5Va.. Alle-11 <br /> Owner a v., a dVIC Address Q rn e <br /> A SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ® OTHER 3 V I-OpS- <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 r <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity ' No. Units Served <br /> 7. ❑ LAUNDRY For July f, -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 h prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d s and regulations f the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> w� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 1 17i PER SITE' ' ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8,Received By July,31 <br /> + BASE EXPLANATION BILL R TANCE $ AMOUNT DUE CHECKED <br /> TE REMITTED AMOUNT <br /> FEE X151- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rn ) Vf/moi 13 (3 -7 Cl <br /> Received by Date Receipt No. Permit No Is nuance Date Mailed De11 red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5 TO CA 95201 <br />