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Applications Will Be Processed When Submitted Properly Completed. Be Sureb',Sgn The Appllgati0tn <br /> APPLICATION 11 '`i L <br /> 4i� (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT ^', <br /> LIQUID WASTE <br /> Application is hereby madeto carry on business in the jurisdicti nal area of the San Joaquin i`Health Dist ri t <br /> yBusiness NameBA) I L! Addresses <br /> a Owner—_ —t_ems (t)' �,I �( Address <br /> Firm Partners, Addresses anTelephone Numbers _ <br /> a Business Telephone No. "! --/ <br /> a Emergency Telephone No. _ <br /> Contractor Licence No. 30 , <br /> 4 _ - <br /> SFJ <br /> L Applicants Name {Print} _ _ Title _ _ Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 .__ Disposal Sites C_, <br /> Description(Make/Yr., Color) --� <br /> Serial No. _ CAL. License No. _ CAL. License Renewal No. _ <br /> Capacity Gal„ Weights &Measures No. <br /> Equipment Parking Address_. <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ R.S. or R.C.E, No. <br /> Test Location Test Date/Time _ <br /> 4. ❑ SANITATION PERMIT C� 6- <br /> Job Address/cation <br /> Address r C y Q <br /> Owner �} Q <br /> SEPTIC TANK ❑ CESSPOOL XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 T! <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 _ <br /> Operator Name _ _. Where Certified <br /> Plant Location - <br /> Plant Capacity_ - _ 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 /> I hereby certify that I have prepared this lication and that the work be done in accordance with San1Jo4t uin County <br /> ordinances, state laws, and les n g�Jla s of the San Joaqui nc I H alth District <br /> C <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH — ❑ January 1. Rec ed By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCt? $ REMIT <br /> BASE E?(PLANATION \ - AMOUNT DUE CHECKED <br /> DATE — DATE ; REMITTED AMOUNT <br /> FEE ; <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER - - -- - <br /> T <br /> OTHER <br /> Received by Date Receipt No, Permit No - Issuance Date --Mail Delivere G <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK N,CA 9 01 <br />