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1laations Will Be Processed When Submitted Properly Cap1181ea- o- <br /> App m <br /> APPLICATION <br /> (For Nan-Transferable,Revocable,and Suspendable) SEQTAGE <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> 'Jf LIQUID WASTE <br /> O. <br /> Application is hereby made to carryon business in the jurisdictionalAa�a e s /�the San Joaquin.local Health District <br /> IrSn <br /> Business Name (DBA) Address <br /> z Owner ` <br /> I Telephone No. <br /> 0 Firm Partners, Addresses and Telephone Num ers Emergency <br /> 3_If <br /> t <br /> ILL Business Telephone No. /G Date �� <br /> Contractor Licence No. <br /> Title �' I <br /> L Applicants Name (Print) <br /> ry (i-7) and Fill in the Required Information <br /> Please check Applicable Catego <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FFORACS a VEHICLE) <br /> Disposal <br /> � <br /> For July 1, June 30, 19 ; <br /> CAL. License RenewalNo. <br /> Description(Make/Yr., Color) CAL, License No. <br /> Serial No. <br /> Gal.,Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> Z• ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. 1l SANITATION PERIM <br /> Job Address/Location Address a <br /> Owner S ❑ PACKAGE PLANT 0 <br /> IH SEPTIC TANK ❑ CESSPOOL 5Y LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> NEW ❑ REPAIR <br /> Off'PERMANENT ❑ TEMPORARY <br /> ® <br /> g, ❑ CHEMICAL TOILETS For July i, -June 30, 19 . <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 4 g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> I Operator Name <br /> Plant Location No. Units Served /C <br /> Plant Capacity <br /> l �, ❑ LAUNDRY For July 1, -June 30,�9More 1,000 Sq. Ft. ~ <br /> f SIZE'. <br /> ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> l <br /> I, application and that the work will be done in accordance.with San Joaquin County. <br /> I hereby certify that l have prepared this appDistrict. <br /> ordinances, state laws, and ru and regulations of the San Joaquin Local Health Distrlc . <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> �Ivly 5 &Received By July 31 <br /> n a ,. 1'BtA�cedi+d.&ya>ianb REMIT <br /> Fee is Due: ❑ ANNUALLY ..f ❑ PE '[l`tdfi'= ' PEp'SiY=P:EFI''"`'-'-.0❑'' �' $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> e <br /> BASE EXPLANATION DATE DATE <br /> r_ <br /> l FEE '.i -� �� `•c,=,; :3:�`!-�,,:.�::�a.�. .v._-:Y ,:;:— <br /> t LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> f <br /> OTHER % .�• <br /> - s <br /> OTHER <br /> f � y <br /> • .fit '", � ���_ Delivered <br /> i7 Iss celDale Mailed <br /> iiz"�'D�te"�"' "r" `-Recefpt`No.•'"-' -'�-^''`"' 16p1 E.HAZELTON AVE..P•C•9ox 2009 STDCKTON,GA 95201 <br /> Received by <br /> � URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT—RET <br />