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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Sus <br /> pendabls) i <br /> ENVIRONMENTAL HEALTH PERMIT ;E;rnGE <br /> AP lie LIQUID WASTE <br /> ? ation is heresy rnadg t0 Carry on business in the jun dichonel area of the San Joaquin Local Health District <br /> a Business Name,(D9A) -- �, 7 <br /> b Owner <br /> ��•- _ ...-- Address <br /> '��' ♦ \C t tt - Address _ ��" <br /> Firm Partners, Addresses and Tel h n �- <br /> p o e Numbers. <br /> g Business Telephone No y E - �- I CG..!- <br /> 7 Contractor Licence No <br /> - - <br /> __- Emergency Telephone No <br /> - - -- <br /> a L Applicants Name(Print) <br /> Phase cheek Applicable Category ) �t Title <br /> 9 rY(1-7 and Fill In the Required fnl ation - Date <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1,__ June 30. t9 <br /> Description(Make/Yr., Color) Disposal Sites <br /> Serial No. -- --_--._ <br /> CAL.License No. - - _► <br /> Capacity,—- GAL, Weighs 3 Measures No._ -- —CAL.Llec.is•Rentila,aI No. - <br /> Equipment Parking Address -- - - -- <br /> 2. ❑ PUMPER YARD ----- - - ir <br /> - <br /> For July 1.__ June 30. 11 ---� - _ <br /> No.of Vehicles Stored _ t <br /> No.of Chemical Toilets Stored. -- <br /> 3. ❑ PERCOLATION TEST 'J <br /> R.S.or R.C.E.Name _- —- W <br /> Test`petition - ____ _-_ R.S.or R.C.E.No. O <br /> ,• UrSANITATION PERMIT - "`--` Test Date/Time <br /> Job Address/LOC tion -__ _ ;,-,r - �O (� <br /> Owner_ - ----- -S i ti=r+►�s�.. <br /> rl-c r� <br /> SEPTIC T D r, r - Address__, __�_ <br /> �PERMANENT ❑ TEMPORAFv �(r NEW t. HIND FIELp �JSEEPAOE PIT ❑ FA AQE AIT <br /> - L ✓ <br /> S• ❑ CHEMICAL TOILETS For Jul• 1. - Ga-REPAIR_ ❑ OTHER�jc_� <br /> June 30, 19 -dC�F •X�� <br /> Type Construction _ _ _ <br /> No. of Units Disposal Site <br /> — ------ Equipment Storage/Cleaning Locatlon(s) —� -- ---- <br /> d• 13 PACKAGIE TREATMENT PLANT For July 1,-June 30, to <br /> er �- - <br /> --- <br /> oetor Name -- - <br /> Plant Location 1Nt ere Cis"Wad _ <br /> Plant Capacity__ -- -- - - <br /> , 7. ❑ LAUNDRY For Julyt. June 30. 9 -- No.Units 3erwd <br /> 1 S12E: ❑ Less Than 1.000 Sri Ft., G More Than 1,000 Sq,Ft, <br /> ❑ DRY CLEANING,Chemicals Used/AmocitvMo. <br /> l� <br /> ).i 1 hereby certify that I ;'Ave Prepaild this application and that the work will be done in accordance with San JoaquinCpunty <br /> ♦b <br /> Ordinances, state Idws, And rubs atd regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X a" <br /> Y - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUAtI Y ❑PCR UNIT O PER$ITE Q I EACH !❑ Jatnwry BY Janwry 31 Q,M,/y 1 a R�tew�p BY Juq Jt <br /> BASE fI1Pl.ANAT ON BtI.LIND REMITTANCE <br /> - DATE s Rl!" <br /> FEE —" _-.-- DATE REMITTED AST OIJE CMEf:KEp <br /> yS" AMDtpr► <br /> _ _ <br /> `PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �— ---- - -- --- .. -- — <br />