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} APPLICATION <br /> Non-Transferable, Revocable,and Suspendabl <br /> ENVIRONMENTAL HEALTH PERMIT SPPTAGE <br /> LIQUID WASTE - <br /> Applicati reliyf�a e t rry Q.n business-in the jurisdictional area of the Sa Joaquin al He Ith District <br /> rBusiness Na DBA �1rG �hhG� ,� / Cz �;t0�.3 yklf <br /> v, l ) Address <br />' < Owner_ Address <br /> Firm Partners,Partners, Addresses and elephone Numbers <br /> aBusiness Telephone No. 21-. 66 BYEmergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) lie Title Title Date 1 <br /> Please check Applicable Category (1-7).and fill in the Required Information <br /> I. ❑[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. CAL, Liccse Renewal No. <br /> Capacity Gal., Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑!PUMPER YARD is <br /> For July 1, June 30, 19 i <br /> No. oi'Vehicles Stored <br /> No. ofChemicalToilets Stored <br /> 3. ❑`#PERCOLATION TESTR.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑EsSANITATION PERMIT I I. <br /> Job Address/Locations <br /> Owner 1 10 MAW ti .Address <br /> Q <br /> 99 SEPTIC TANK b CESSPOOL GL1 LEACHING.FIELD 0 SEEPAGE PIT ❑.PACKAGE PLANT {4 <br /> ❑ PERMANENT ❑ TEMPORARY IR NEW, 0 REPAIR ❑ OTHER <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 <br /> i Operator Name Where Certified k <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 0,1 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 /> } Ik <br /> ii <br /> i 31 <br /> 1� I hereby certify that I have prepared this application and thatpe work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and regulationse S6an_J uin Local Health District. <br /> if <br /> APPLICANT'S SIGNATURE X it l�Yh ✓r �- r,�� <br /> it i� • _ <br /> .i� <br /> FOR DEPARTMENT USE ONLY <br /> 'Fee IS Due: ❑ ANNUALLY. ❑.PER UNIT R PER SITE ❑EACH 13 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> l REMIT <br /> p BILLING REMITTANCE S <br /> BASE is EXPLANATION DATE. DATE REMITTED AMOUNT DUE CHECKED <br /> u1 AMOUNT <br /> ,FEE <br /> LESS " <br /> PRORATION u, <br /> ,PLUS l <br /> 'PENALTY j. <br /> :OTHER w� <br /> ei. <br /> ?'OTHER it <br /> Received by Date li Receipt No. PerfAit No. Issuance Date Mailed Delivee d. <br /> 'APPLICANT—RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.-HAZELTON AVE.,P.O.Box 2009 , STOC ON,C <br /> i <br />