|
rr,
<br /> I J
<br /> ...-�o,.,.gl„xf,rn•+.:,r-,,. .4-Ld# .vim.... �.. ,. �. .. ,..'..� .. .�..... - ,_ .. ..:.�. -. �i��`�� ,
<br /> Applications Will Be Processed When Submilled Properly Complsled.Be Sars To Sign The Application.
<br /> St APPLICATION i
<br /> ° y (For Non-Transferable,Revocable,and Suspendable) ,T r,r '•I
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WAZTE
<br /> ar' Application is•hefeb adeto o tyussf s in the urisuictional aI?a of the San?..,quln Local Health Distri t
<br /> Business Nast (DEiA a Cl ��o V ��\1 —_Addrea3_r-1�
<br /> �� ,
<br /> Owner •_ � /�' --. — Address.— --
<br /> a Firm Partners,Addresses and Telephone Numbgrs_—
<br /> Business Telephone No.l�lr✓1^a 6� Emergency Telephone No.
<br /> Y- -i Contractor Licence Na.���c r .�~,�+---�•- --- 1
<br /> —�• / - fir
<br /> �.Appl:cants Name(Pring— _ --�-rd <- Title Date !
<br /> aa.
<br /> i Please check Applicable Category(1-7)and FIII in the Required InlormWIcn ( �
<br /> 1_13 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE}
<br /> Fo:-Juty 1, June 30. 19- Disposal Sites —
<br /> Des,1ption(Make/Yr.,Color) ------- --- —CAL..License No. CAL.License Renewal No. x
<br /> r „Y -
<br /> Serial No
<br /> Capacity Gal..t Gal,°Weights Measures No.
<br /> r' Equipment Parking Address—_ w— - --- -
<br /> 2.' ❑ PUMPER YARD
<br /> 4' 'For July t, June 30,19_- {
<br /> r; No.of Vehicles Stared -
<br /> No."of Chemical Toilets Stored ----
<br /> 3 ; O PERCOLATION TEST }'
<br /> R.S.zor R,C.E.Name R.S.or R C..E.No. —
<br /> Test Location ---. lest
<br /> C'. !Time
<br /> r / T
<br /> ff 4. K�-SANITATION PERMIT S� ,AIX' � f 4
<br /> '•Job Address/Loc do
<br /> Owner. _' �_... Address
<br /> g Cl SEPTIC TANK ❑ CESSPOOL' 13 LEACHING FIELD ❑ SEEPAGE FIT C1 PACKAGE PLANT ;
<br /> t aF
<br /> PERMANENT ❑ TEMPORARY ,0 NEW .�EPAfii OTHER �[1 xjID
<br /> C] CHEMICAL TOILETS For July 1,-June 30. 19 yyf
<br /> tKType Construction - Disposal Site - .?
<br /> }5 No.of Units Equipment Storage/Cleaning Locations)
<br /> i' 6.`❑ PACKAGE TREATMENT PLANT For July 1,-June 3C, 19
<br /> _—Where Certified
<br /> Operator�Name
<br /> . Plant Location
<br /> tr,.. Plant Capacity „No.Urtits Served
<br /> 7..IC]•LAUNDRY For July 1,-.lune 30,19
<br /> a. SIZE: ; ❑ Less Than 1,000 Sq,Ft., 0 More Than 1,000 Sq.Ft. r„
<br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - ---- -
<br /> vix .
<br /> I hereby certi at ve p[ a d�r7e ?ns
<br /> „'b�tion-@nd pratthe work will be done in accordance with San Joaquin Countyordinances,state laws,and andof 1`re San J qwn Lo al HE'alth �t.APPLICANT'S SIGNATUREX J { - ``� •��h/
<br /> cifla� 0c7
<br /> '^ r - FOR DEPARTMENT USE ONLY ;
<br /> ,{ -! FEO Is Due:❑ ANNUALLY ❑PER UNIT - ❑ PER SITE - CJ C3 C3January 1$Rece+ved By January 31 ❑ July 1 b Rece,ve0 By Ju;y 31
<br /> _ _ REMIT
<br /> BILLING REMIY TANCE ! S AMOUNT DUE CHECKED
<br /> (� BASE EXPLANATION DATE. I DATE I REMITTED _- AMOUNT Syp7
<br /> '5
<br /> �FE
<br /> LFEE 4
<br /> LESSLESS
<br /> _
<br /> AAT:DN _
<br /> PLUS I -J[/� �w -••�r 7l
<br /> PENALTY _ 1�'-I. __. __ - __.— -.-.-- --`-` -- -- _-_•_-.
<br /> OTHER
<br /> IE OTHER
<br /> Reeewea Gy --�_-_ -D+t'�_ .~•..- Nncr,p,No Pv,rntt 110 _ / Issuahce Oaiq,�Marled nehvered
<br /> APPLICANT-RETURN ALL COPIES to: LNYIRONMENTAL HEALTH PERMIV5LRYICFS 1601 f,HAZELTON AYE..P-O.60.2009 STOCKTON.CA 95201—
<br />
|