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Y Applications Will Be Processed When Submitted Properly Completed.Be Sure To SignThAppllcanon. <br /> APPLICATION 'S -- <br /> (For Non-Transferable,Revocable, and Suspendable) SEP TAGS <br /> ENVIRONMENTAL HEALTH PERMIT _ <br /> LIQUID WASTE ' <br /> Application is hereb made to carry on business in the jurisdictional area of the San Joa uin Local Health District <br /> rn Business Name (DBA) Address <br /> a Owner Address - <br /> �. <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _ Pte. _ Emergency Telephone No. <br /> I ;Contractor Licence No. " <br /> LApplicants Name (Print) CA <br /> � Title Date <br /> Please check Applicable Category.(14)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For-July 1, i June 30, 19'- - --Disposal Sites _ <br /> 'Descripfion(Make/Yr:-, Color)"'""`"' -"'•' �._._..W.._.. ��' _ ��..,.K����� � ��� <br /> Serial No. KCAL-license No:. 4 CAL. License Renewal No. <br /> w_ " _ - I t <br /> Capacity _ Gal., Werghts,&Measures No + <br /> Equipment_Parking Address <br /> r 2. <br /> El PUMPER YARD <br /> For July 1, June 30, 19 I <br /> No. of Vehicles Stored s a <br /> No, of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i # <br /> R.S. or R.C.E. Name f R.S. or R.C.E. No. a <br /> Test Date/Time <br /> est Location 1 <br /> 4. B ANITATION PERMIT'' v i 3 r� <br /> t Job Address/Location Zs �' ` <br /> f Address's <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL ®LEACHING FIELD I SIEEPAGE PIT r , <br /> C-F)fRMANENT 1:1TEMPORARY 13NEW } -`LAR PAIR 11 OTHERy <br /> -5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' �+ <br /> ' Disposal Site <br /> Type Construction I <br /> No. of Units Equipment Storage/C lean ing.Location(s) <br /> 3 <br /> 6. ❑ PACKAGE'TREATMENT PLANT} For July 1,_'=June 30, 19 s ) <br /> - Where Certified <br /> Operator Name <br /> r - <br /> Plant Location <br /> Plant Capacity I No. Units Served - <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 /> J � m � <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin Gounty a <br /> ordinances, state laws, a s and regulati s of the S aquin 1 He th District. t` ft <br /> APPLICANT'S SIGNATURE X i <br /> !j tFDA 6EPARTMENT'USE ONLY i i <br /> Due' O'ANNUALLY ❑ PER UNIT [1,P ER_ SITE '❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $Received By July 31 <br /> Fee Is <br /> i_ �# <br /> (( `BIl.L1NG -REMITTANCE - $.�d � AMOUNT DUE CHECKED <br /> 7EWLANATtON PATE `DATE "' -"REMITTED+ry AMOUNT <br /> y <br /> 3 �. # � - �• 4 �-7L��'�i�t1 yam, <br /> 4 FEE <br /> 1 1i o <br /> t LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> ,r• OTHER <br /> /T tOTHER - <br /> t� • 3 <br /> Received by Date Receipe No. _�`i=� Permit No. ss ce D to Mailed Del'wered <br /> i <br /> �" '"'APPLICANT-RETURN ALL COPIE$.TO:"-"`ENVIRONMENTAL HEAiTH P�RMITISERYICES _ �- 1601 E.H AYE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />