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^rr••""••"•"' •••••�+� • .vocaacu .. .vn v 1111 U rr VPWPI r 1 V111}AC\tlu. oC Ou t: I atyn 111V NPPIIcilllon. y <br /> APPLICATION .� <br /> ? Non-Transferable, Revocable, and Suspendabl:"i..." l <br /> ENVIRONMENTAL HEALTH PERMIT ��' W <br /> LIQUID WASTE <br /> Applicatio is hereby m e to carry on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> L Business Name (DBA� 1 � U�C�. Address <br /> a Owner- �z'�f{ Address �" 1� <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. _. <br /> Contractor Licence No. 3 -s- j _ <br /> Applicants Name (Print) Title ��+ Date "f <br /> Please check Applicable Category (1-7)and Fill in a Required Information <br /> 1. ❑ PUMPER VEHICLE}PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July t, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal-, Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD v <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4.X SANITATION PERMIT fj <br /> Job Addr s/Location ? <br /> Owner Address' _ /D� irf <br /> 13SEPTIC TANK ❑ CESSPOOL OfLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLAT <br /> 19rPERMANENT <br /> L T <br /> PERMANENT ❑ TEMPORARY ❑ NEW 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 /> Operator Name Where Certified <br /> Plant Location _ <br /> Plant Capacity No. Units Served <br /> 7. ❑ 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 /> r 4 <br /> 5 <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, s and regulation of the San aquin Local Health District. <br /> 6 � <br /> APPLICANT'S SIGNATURE X zt <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE, $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE :A/ <br /> LESS loll <br /> PRORATION e <br /> PLUS .. <br /> PENALTY <br /> OTHER <br /> OTHER <br /> :�.%77 �- <br /> �-g 0 _ <br /> Received by Date Receipt No Permit No, Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTQN AVE.,P.O.Box 2009 STO�1� ,C 95201 <br /> S t� <br />