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_ a <br /> Appl cations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �� ? ? APPLICATION <br /> (For Non-Transferable;Revocable;and Suspendable) SE=PTAGE <br /> ' ENVIRONMENTAL HEALTHY ERMIT <br /> l LIQUID WASTE <br /> Application ' r made I rry on bu ess in the-jurisdictional area of the San Joa uin LOG I Health trict <br /> yBusiness Nam BA} :1 Addre <br /> z Owner 9 Address.... t <br /> P Firm Partners, Addresses and Telephone Numbers <br /> a ;�I111111 le Emergency Telephone No,- <br /> CL Business Telephone No. _ _ - , <br /> Contractor Licence No. 10: i <br /> LApplicants Name(Print) IE Al Title — Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information s <br /> 1. 13 PUMPER VEHICLE PERMITr`,REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19' bP - '--Disposal Sites - -- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity l� Gal., Weights & Measures No. ` <br /> Equipment Parking Address �H <br /> 2. ❑ PUMPER YARD <br /> For July 1,-' — June 30, 19 <br /> .No. of Vehicles Stored <br /> No. of Chemical Toilets Stored �� F <br /> 3. ❑ PERCOLATION TEST I I <br /> R.S. or R.C.E. Name I 4 R.S.or R.C.E. No. <br /> Test Location - Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner li Address <br /> SEPTIC TANK C31 CESSPOOL' EACHING FIELD JKSEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW f~ 4>WREPAIR ❑ OTHER <br /> ; r-x 3 l I <br /> 5. 11 CHEMICAL TOILETS 'i or,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 E <br /> Operator Name ' Where CertifiedJha <br /> Plant Location <br /> + �r No. Units Served' I i. r <br /> Plant Capacity � � , , <br /> r .r,., -4— <br /> :SIZE: <br /> 11 LAUNDRY For July 1;--JP,ne 30, 19 � ' - - *,� <br /> :SIZE: ❑ Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DqY CLEANING Chemicals Used/Amount/Mo. <br /> i Homeawneror.licerseclagen#'ssiennlft;?cp:;"ss:ij.:1h ?�li+'tunt7 "!Cortiyi??:iin'h;Fc' ;nnr:!P.-.Cnfthevorkloi:-hic?itltispermitisissued,lsha <br /> .. In SIFCh manner d5 t0 bEl.onre SL'l}I£Si ii;'J!(l:;;iS:c�:?'S ccl;:rev,:S2lia^i8Vd5 Jt(:alkiGf�];L ' I Controctor's hiring o. sub-cnnl�=aclina sia,a <br /> ture durtifi" the following: J certify that in the perfoimaiceo��the taark for which this pe <br /> employ persons sub}ect to workman's co,rpensatton lags of calii0mia:' <br /> I hereby certify that Itave prepared this application and that the work will be'done in accordance with San Joaquin County <br /> ordinances, state Iawsil and a and regulati of the n Joaquin Local Health District- <br /> APPLICANT'S SIGNATURE X II 1Q' <br /> J <br /> � t � <br /> t ; . <br /> FORIDEPARTMENT USE <br /> Fee Is Due.❑ ANNUALLY II, ❑ PER UNIT ❑ PER SITE W ❑,EACH da y '&Pleceived By January 31 ❑ July 1 &Received By July 31 ` <br /> .-T - REMIT <br /> BASE' EXPLANATION BILLING" RE AN $ AMOUNT DUE -CHECKED <br /> � <br /> DATE AT REMITTED AMOUNT <br /> FEE '• `` _ LTn 5 <br /> ,-" - _ <br /> LESS <br /> PRORATION - f" <br /> 1 PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I LLL <br /> Received by DateReceipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: `ENVIRONMENTAL HEALTH PERMIT CES+ 1601 E.HAZE TON AVE.,P.O.Box 2009 STOCKTON,GA 85201- - <br /> ''II GY' /D�Z•7 � .��' <br />