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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> �. ..z <br /> APPLICATION v <br /> (For Non-Transferable, Revocable, and Suspendable) SE PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address - <br /> aOwner h� a'QRn �- J41� il� C Address jag 9 /= jcjrC�T Cts <br /> u Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. - Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill In the 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 /> III Serial No. t ! CAL. License No. CAL. License Renewal No. <br /> Capacity ` '�' Gal.,Weights&Measures No. <br /> Equipment Parking Address r• <br /> I- 2. ❑ PUMPER YARD 1 v <br /> For July 1, June 30, 19 <br /> 1 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 a r 'Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location A 4 9 <br /> t Owner "It 92 IT <br /> SEPTIC TANK 11CESSPOOL V LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I1KPERMANENT ❑ TEMPORARY JIM 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 /> j <br /> Operator Name Where Certified <br /> I Plant Location - - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. . — <br /> 1 •. <br /> t <br /> 4. <br /> I hereby certify that I have prepared-ti application-an that_fhe work well be done in accorderfce with San Joaquin County <br /> ordinances,state laws, and rules andulations owe San quln Local,Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> > ( t FOR DEPARTMENT USE ONLY <br /> t <br /> F@!Is Due: ❑ ANNUALLY ❑ PEP UNITtL3111 t3 PER SITE i ❑ FJ1CH t❑ January t a Received By January 31 ❑ July 1 S Receivetl By July 31 <br /> I REMIT <br /> BASE EXPLANATION (�'BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> l FEELESS <br /> Z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> p <br /> OTHER " <br /> OTHER t <br /> 'P r 6yd 113y71i <br /> Re"Wed by^ �, at - ..--.. Recelpt No. ; Permit No:—^ lea nce. te��Meiled ever <br /> A <br /> ERe,nnmwpwAI HPALYM PERIJIMMERVICES INI E.HAZELTON AVE..P.O.Dal 4609 STOCK N,.0 <br />