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t? Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> . _ APPLICATION - v 3 0 -1018 0 <br /> x F <br /> y =. (For Non-Transferable,Revocable, and Suspendable) : <br /> ENVIRONMENTAL HEALTH PERMIT 5 P7AGE <br /> w; <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District ` <br /> 1 m Business Name (DBA)_ Q7-6- ANOTIE61! 5!5CQI4-E Address/'76- S5, Q % <br /> f*q Owner. W 461-CH - Address _ � 5­ <br /> 2 Firm Partners,Addresses and Telephone Numbers <br /> r <br /> aBusiness Telephone No. �/� "a Emergency Telephone No. <br /> Contractor Licence No. + t = <br /> L Applicants Name(Print) - 1r Title T Date 2 <br /> Please check Applicable Category (1-7)and Fill in the Re uired 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 No. CAL. License No. CAL. License Renewal No. <br /> Gap city Gal., Weights 11 Measures No. <br /> EquipmentParking Address <br /> 2. E] PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> INo. of Chemical Toilets Stored <br /> 13. ❑ PERCOLATION TEST'S °a <br /> IR.S. or R.C.E. Name i --Z R.S. or R.C.E. No. <br /> jTe <br /> Test Date/Time st Location E+1 <br /> 4. SANITATION PERMIT <br /> 9934, <br /> ,Job Address/Location <br /> Y .'Owner Address d O La e_ ` <br /> 1 ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> l ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> i <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, <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 /> f 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 1,0 Sq. Ftw"ni� <br /> 0DRY CLEANING, Chemicals Used/Amount/Mo. <br /> rr t N. <br /> r 1 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,.a sand,regula_ti _S of the, an Joaquin Local Health District. <br /> r 'APPLICANT'S SIGNATURE X �^ Y <br /> FOR DEPARTMENT USE ONLY kk, <br /> Feels Due ❑ ANNUALLY_- ❑.PER UNIT PER SITE f ❑ EACH ❑ January 1 &Received By January 31f ❑ July 1 &Received By July 31 <br /> REMIT <br /> B. AMOUILLING• REMITTANCE ��� [9"f a , <br /> BAS.E.: _ EXPLANATION w. . ..". NT DUE CHECKED <br /> DATE DATE- y_ REMITF AMOUNT } <br /> FEE s 's✓ <br /> U <br /> F PRORATION n 4 �"�-- <br /> .` PLUS <br /> PENALTY __ F <br /> 10TH{R -.'k c• Z �� 4 +� <br /> OTHEH <br /> RBCBived by --Date-� Receipt No. - - Permit No Issuance Date Mailed Deliver ON,CA 95201 <br /> ., <br /> ,APPLICANT—RETURN�ALL COPIES TOt' -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P"O.Box 2009.-. 'TOC <br /> y f, <br />