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Applications Will Be Processed When Submitted Properly Completed. Be Sure Iosign I"t! <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) $ pTAGE <br /> `may ENVIRONMENTAL HEALTH PERMIT <br /> �r LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of theSan Joaquin c It��o �s !d 135 3 <br /> N Business Name (DBA) <br /> Address <br /> aOwner mel`!rA.aelk Address <br /> Firm Partners, Addresses and Telephone Numbers Emergent Telephone No. ' <br /> Emergency <br /> a Business Telephone No. S 3— `/ / 1 <br /> a `� v`cS'� <br /> Contractor Licence No. 6— o�yT�--r-T} Date �` <br /> Title _C <br /> Applicants Name (Print) <br /> T <br /> Please check Applicable Category (1-7)and Fill in t e Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites t <br /> Description(Make/Yr.. Color) CAL. Liccase Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD } <br /> For July 1, June 30, 19 tt <br /> No. of Vehicles Stored i <br /> r <br /> IVa. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. 1? SANITATION PERMIT <br /> Job Address/Location Jct <br /> Owner w/')Al ��� Address h <br /> ❑ CESSPOOL Rr LEACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT —i <br /> ® SEPTIC TANK 11 REPAIR ❑ OTHER <br /> 50 PERMANENT ❑ TEMPORARY <br /> 11 NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> t Operator Name O <br /> Plant Location <br /> No. Units Served <br /> [ Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 L <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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules Wd regulations of the San Joaquin Local Health District. <br /> i APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT �EH SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received REMIT <br /> YuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> !!! FEE ` <br /> LESS <br /> PRORATION <br /> S <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> # OTHER <br /> _ Issuan a Date. Mailed Delivered <br /> e ved by Date Receipt No.� Permit No. <br /> q - - 1601 E.HAZELTON AVE;P.D.Box 2009 STOCK ,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES a <br />