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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) <br /> ENVIRONMENTAL HEALTH PERMIT SPPTAGE <br /> .S� <br /> LIQUID WASTE <br /> Applicati is h y made to c r business in the jurisdictional area of the San Joaquin LSI , al Is ct i y <br /> yBusiness Na e ry J Addresses a <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers G <br /> Q. Business Telephone No. IM Emergency Telephone No. <br /> Contractor Licence No. r <br /> L Applicants Name (Print) Title Date <br /> i <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, 1911 Disposal Sites <br /> I Description(Make/Yr., Color) 11 <br /> Serial No. 1�. CAL_. License No. CAL. Lirznse Renewal No. <br /> k Capacity ry� Gal., Weights & Measures No. <br /> Equipment Parking Address 11. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 N V� <br /> No. of Vehicles Stored IN <br /> k No. of Chemical Toilets Stored1 G <br /> fi <br /> 3. ❑ PERCOLATION <br /> TEST-R.S. or R.C.E. Name I—ry t R.S. or R.C.E. No. <br /> Test Location ��` Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> SEPTIC ANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY EW ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J e 30, 19 <br /> t Type Construction Disposal.Site.,,, _ <br /> Z No. of Units Jl; Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT-PLANT For July 1; ---June 3 , 19 <br /> j�: <br /> Operator Name 3_iWhere Certified <br /> E 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., 11More Than 1,000 Sq. Ft.� - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> R 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 and regulati �then Joaqu�Lcal_Health District. <br /> �. <br /> APPLICANT'S SIGNATURE X <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> iF <br /> e Is Due: ❑ ANNUALLY) [3 PER UNIT s PER SITE ❑ EACH ❑ January 1 &Received By January 31 �}*July 1 &Received By July 31 <br /> - REMIT <br /> A.' BILLING ��REMITTANC $ AMOUNTDUE CHECKED <br /> BASE EXPLANATION _.DATE DATE - REMITTED- - T"` <br /> II _ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I6 1O 3ti1� <br /> PENALTY PPP <br /> OTHER <br /> ii OTHER <br /> 7 717 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Del ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.;HAZELTON AVE.,P.O.Bow 2009. ST CKTON,C <br /> 11 _�� <br />