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Applications will Ue Processed wnen supmmea Properly trompletea. r e sure 1 u algn 1 me ►PPk1cauun. <br /> J APPLICATION s <br /> �.- -a (For Nan-Transferable, Revocable,and Suspendable) f <br /> --� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE a <br /> Applicatio Is hereby me to carry on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> BusineYs Name (DBA) •�` Ud � Address_Z'z <br /> Owner_.._ Address -......---- <br /> Firm Partners, Addresses and Telephone Numbers --- <br /> Business Telephone No. -� " 's" Emergency Telephone No. <br /> Contractor Licence No._ .T ,� — ____— _ <br /> ' Applicants Name (Print) - Title . 5,2,7 Date <br /> i f ^ <br /> Please check Applicable Category (1-7) and Fill in e Required Information <br /> 1. ❑ PUMPER VEHICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description (Make/Yr., Color),---- <br /> Serial <br /> olor)_Serial No. CAL. License No. __ CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. — <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemicai Toilets Stored t, <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name A.S.or R.C.E. Na. <br /> Test Location Test Date/Time - <br /> 4. SANITATION PERMIT 1 .fir .� <br /> Jab Addr s/Location � it <br /> � <br /> Owner X16 Address Y <br /> ❑ SEPTIC TANK ❑ CESSPOOL fig LEACHING FIELD Xr SEEPAGE PIT ❑ PACKAGE PL T <br /> PERMANENT ❑ TEMPORARY ❑ NEW FREPAIR © OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units ___ r__ 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 GLEANING, Chemicals Used/Amount/Mo. <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 Paquin Local Health District, <br /> APPLICANT'S SIGNATURE X -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT W PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received i3y July 31 <br /> T REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE -f ' 13 t�- <br /> LESS <br /> PRORATION tri <br /> PLUS <br /> PENALTY <br /> OTHER p�r <br /> OTHER <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.HAZELTON AVE.,P.O.Bok 2009 STO ,C 95201 - <br />