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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> `.p 0 m.N. APPLICATION <br /> ".__; (For Non-Transferable, Revocable, and Suspendable) <br /> � <br /> /z= S� ENVIRONMENTAL HEALTH PERMIT S�PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 1 <br /> . Business Name (DBA) ASW <br /> J`�z'IId Address 1'fS "� ` <br /> z Owner !L- Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers I <br /> Business Telephone No. z- `3 Emergency Telephone No. i <br /> Contractor Licence No. -5 <br /> LApplicants Name(Print) FLo h ®0� Title Date 7�L g`Sp <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CRL. License 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.G.E. Name R.S. or R.C.E. No. <br /> x <br /> Test Location Test Date/Time <br /> 4. ,K SANITATION PERMIT <br /> Jab Address/Location S ire <br /> Owner LA Ali' 0- Address �• .�f aP ZA-7 `� <br /> W SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY R[ ❑NEW REPAIR ❑ OTHER <br /> CHEMIC Y <br /> 5. <br /> ❑ AL TOILETS For Jul 1,-June 30, 19 (9 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <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 /> F <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, and rules and regulations o San Joaquin Local Health Disti <br /> APPLICANT'S SIGNATURE X <br /> r <br /> Y <br /> FOR DEPARTMENT USE ONLY v <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED IS/ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. iss ance ate Mailed "Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 S7OCKTh CA 95201 <br />