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�Tl" ut! riu+ tt!' Bell aULlmuteu Propetly l.UI11pleluu. tae aure ?__%4" Iile AppliCaUUll.- - <br /> APPLICATION k . ' <br /> (For Non-Transferable, Revocable, and.Suspendable) <br /> YFPTAC-E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> IrLIQUID WASTE <br /> 4. }. Applicatierriis hhpreby a to ca on business in the jurisdictional area of the San Joaquin al Hea Di Ict <br /> 3usiness ame ( QA4 " —el _ AddressL�� <br /> _'k"ner -f. Address <br /> = n Partners, Addresses and Telephone Numbers <br /> 36siness Telephone No. Emergency Telephone No <br /> 3 �tractor Licence No. �'/ l <br /> 4 llicants Name (Print) Date l� __ Title 1. <br /> 3�:.Jse check Applicable Category (1-7) and Fill in the Require8 Information �f <br /> t. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> =.July 1, .June 30, 19 Disposal Sites <br /> 7 cription(Make/Yr., Color) <br /> 3erlal Na. CAL. License No. _ CAL. License Renewal No. <br /> .._acity Gal..Weights & Measures No. <br /> = ipment Parking Address <br /> 2!=❑ PUMPER YARD <br /> =or July 1, June 30, 19 <br /> ,r of Vehicles Stored <br /> t <br /> of Chemical Toilets Stored <br /> !. ❑ PERCOLATION TEST <br /> 3n or R.C.E. Name R.S. or R.C.E. No, <br /> r <br /> fk t Location Test Date/Time <br /> 17'_g SANITATION PERMIT <br /> lo.b Addres.5i L_oca Ion <br /> } <br /> gerGi� r! _ _ L Address = , <br /> =. SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT a <br /> PERMANENT ❑ TEMPORARY 13.NEW REPAIR ❑ OTHER .` <br /> i!-'❑ CHEMICAL TOILETS For July 1, -June 30. 19 <br /> T% a Construction Disposal Site <br /> Vo. of Units Equipment Storage/Cleaning Location(s) <br /> i_�3 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 0 <br /> ? rrator Name Where Certified <br /> 'rant Location <br /> dant Capacity No. Units Served A <br /> ?.7":] LAUNDRY For July 1, -June 30, 19 <br /> 3 .-: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F <br /> 1 hereby certify that I t1 ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws and rulasailq regulations of t San Joa uin Local Health District. <br />' APPLICANT'S SIGNATURE X <br /> F _ <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> FIJI Fee IS 011e: ❑ ANNUALLY Q PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> iREMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ OUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> FFEE �Jr <br /> ys <br /> LESS G <br /> PRORATION <br /> PLUS <br /> PENALTY a <br /> OTHER ! <br /> OTHER <br /> I Received by Date Receipt No, Permit No. Issuance Date Mailetleliver d <br /> APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boll 2[1119 STOC TON,CA 95201 <br />