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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. a <br /> APPLICATION -,� l <br /> Al� (For Non-Transferable,Revocable and Suspendable) r �, „SEPTAL <br /> l ENVIRONMENTAL HEALTH-PERMIT / <br /> LIQUID WASTE <br /> Applica 'on is hAreby madetcrcaey on busing in the jurisdictional area of the an Joaq Local Health (strict} <br /> r9usine s ame DBA) c - Address <br /> a Owner <br /> J.Firm Partners, Addresses and glephonee++Number <br /> a Business Telephone No. �. lib—'1b0i Emergency Telephone No. <br /> _J Contractor Licence No. AN <br /> L Applicants Name (Print) U ^. Title..: Date l <br /> Please check Applicable Category (11_( -7) and Fill in,the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, . - June 30,.19 Disposal Sites _ -- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity, Gal.,Weights & Measures No. - V <br /> Equiipment_P-irking Address " <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30119 r ^..'^ `;* ., .. ."""• �.�."' ", e <br /> No. of Vehicles Stored 1 - <br /> 4y_' t. 5 _ i" - ( 3 <br /> No. of Chemical Toilets Stared to <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or.R.C.E. Name 1 h� -T _ R.S. or R.C.E. No. <br /> �T t L cation # �"�-, � 1 / -� " ` to Date/Time I <br /> 4 SAN[TAT ION PER - --T-�� <br /> Job Address/Location <br /> Owner ; Address OLT1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL) IKLEACHING FIELD .,,SEEPAGE PIT- -'❑- PACKAGE-PLANT �. <br /> i PERMANENT ❑ TEMPORARY ❑ NEW ._>ir_REPAIR ❑ OTHER 3 <br /> S. ❑ CHEMICAL TOILETS For July 1, -June-30, 19 w <br /> Type Construction - - -J Disposal Site_� i <br /> ;No. of Units Equipment Storage/Cleaning Location(s) <br /> 6 ti❑ PACKAGE TREATMENT PLANT For July 1, -June-3W'19 <br /> ed <br /> i ' f <br /> Where Certifi <br /> Operator Name. <br /> Plant Location <br /> Plant Capacity �� No. Units Served i <br /> 7. ❑ LAUNDRY For July 1, -jJune 30-19 a <br /> SIZE: ❑ Less Than 1,000 Sq� Ft., ❑ More Than 1,000 Sq. Ft, . <br /> Of DRY CLEANING, Chemicals Used/Amount/Mo. <br /> } <br /> I hereby certify that"91have'prepartd this application and, hat'the work will be done inWaccordance wi h San Joaquin County } <br /> ordinances, state laws€and rules and regulations of the San Joaquin LocalwMealtFi District. <br /> APPLICANT'S SIGNATVREE t, <br /> FOR DEPARTMENT USE ONLY <br /> # 1� Y <br /> Fee Is Due: ❑ ANNUALLY ElPEH UNIT( +;❑ PER%51TF - EACH ❑ January 1 &Received By Janudry 31 ❑ July 1 &R.ceived By July 31 <br /> N BILLING REMITTANCE $ AMOUNT DUE CHECKED';✓ <br /> BASE EXPLANATIO <br /> ! ,. DATE. DATE REMITTED AMOUNT_:J1 ° <br /> FEE �..�.r• -�. _ Q _ - ~� ,1� , <br /> .. - .. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t <br /> OTHER P./PFJ 0- � k <br /> Or`'k <br /> ,. <br /> THER „-. �k� I �rr-, 041 t? P4� <br /> C <br /> Received by - Date ReceipliNd L \_,�yr Permit No. ,; Issuance Date Mailed DOMere . <br /> APPLICANT' RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Boa 2009 5TOCKTON,CA 95201 <br />