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Applications Will Be Processed When Submitted Properly Completed. <br /> � APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPPAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE Ith District <br /> Application is sby ; de to car n bu)See s i he jurisdictional area of the San�.l��ui Loc C. <br /> Address •.�� <br /> F Business Na DBA) Address --S <br /> z Owner <br /> a <br /> Firm Partners, Addresses and lepton plulT1bers f Emergency Telephone No. <br /> aBusiness Telephone No.. ((�� <br /> Contractor Licence No. __1k Title Date <br /> Applicants Name (Print) ` <br /> Please check Applicable Category (1-7) and-Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) l <br /> For July 1, <br /> June 30, 19 " Disposal Sites <br /> Description(Make/Yr., Color) CAL, License No. CAL. License Renewal No. <br /> Serial No, Gal_,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> Z. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. o1 Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 1 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S.or R.G.E. Name Test Date/Time <br /> s <br /> F Test Location + <br /> r10 <br /> 4.,CE�_SANITATION PERMIT <br /> —� <br /> Job Address/Loa n d _ Address <br /> I Owner ❑ PACKAGE PLANT y <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> ❑ TEMPORARY ❑ NEW - EPAIR <br /> �-PERMANENT � - <br /> s 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> Equipmentn <br /> Storage/Cleaning Location(s) <br /> I No. of Units . ' <br /> 6, 11 PACKAGE TREATMENT PLANT or July 1, -June 30, 19 # Where Certified <br /> r r <br /> Operator Name s I <br /> Plant Location - No. Units Served <br /> i Plant Capacity € <br /> 7, ❑ LAUNDRY For July 1,--June 30, 19 <br /> Than 1,000 Sq. Ft. w + v <br /> SIZE: ❑ Less Than 1,000 Sq. Ft•, <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. <br /> I hereby certify that I have prep is a Mica? n and n Jo;qu�inotalhwork will <br /> Heaeth Dstrict done in accordance with San Joaquin County <br /> ordinances, state laws, and rule Fe9io 0 Che <br /> ex <br /> APPLICANTS SIGNATURE r <br /> t FOR DEPARTMENT USE ONLY <br /> - C3Jul., t &Received By July 31 <br /> EACH January 1 &Received By January 31 <br /> ❑ <br /> Fee IS Due: ❑ ANNUALLYY f ❑ PER UNIT PER SITE ❑ REMITTANCEHE�KEfl <br /> SICCING t $ AMOUNT DUE <br /> BASE <br /> EXPLANATION RATE - DATE REMITTEDAs <br /> AMOUNT <br /> g� <br /> FEE <br /> + . F <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ F <br /> OTHER <br /> i, <br /> OTHER <br /> ReceipPermit No, <br /> C 5ua e D e Mailed Delivered <br /> Received 4y Date t No. 1641 E.HAZELTON AVE.,P.O.Box 2009 570CK70N,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />