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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) 5EP7AGE <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 �' �Q�Nr'IA�iGIei u, Address_ ��D N' rT STQG�TiW ��s1Q , <br /> y <br /> z Owner AW0>v WONT Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> a. Business Telephone No. <br /> Contractor Licence No. i G �NCI:� N P�� ID P66 0 <br /> LApplicants Name(Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) rt <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 /> Capacity Gal., Weights &Measures No. 4 <br /> f <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 19 PERCOLATION TEST rn�� 0 �5� <br /> R.S. or R.C.E. Name c R MN)m W ONCr- R.S. or R.C.E. No. <br /> Test Location I 3 3 00 0T f✓ Test Date/Time j <br /> f <br /> 4. ❑ SANITATION PERMIT `I <br /> Job Address/Location <br /> Owner Address <br /> El SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 13 SE <br /> PIT 13 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I 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 /> Where Certified <br /> Operator Name <br /> I Plant Location <br /> Plant Capacity No, Units Served r. <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 /> +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, and rules a s of the S o uin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑'July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE. CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 4 <br /> ( OTHER <br /> zz <br /> Aam <br /> -Y Issuance Da — —Mailed--- -.,Delivered ' <br /> Received by ate Receipt No. Permit No: —�— <br /> 4 APPLICANT-RETURN-ALL COPIES T RNEO tv1Y ONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5T4GKTON,CA 9520 <br />