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Applications Will Be Processed When Submitted Properly Completed. Be SureTosignTneAppucauon. k <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP�AGE <br /> � LIQUID WASTE <br /> Application is er y made to carry�n business in the jurisdictional area of tJ San Joaquin��al�HeI,th_District <br /> HBusiness Name (DBA)n � -r Address <br /> �� Address <br /> z Owner <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �b— GO Emergegcy Telephone No. <br /> a Contractor Licence No. ;u.—✓�-3 "` <br /> ZL <br /> Applicants Name (Print) a Elio "µ Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. Licc,ase Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> } <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 /> i r <br /> Test Location Test Date/Time <br /> 4. gSANITATION PERMIT <br /> Job Address/Locat'on j <br /> Owner �� Address �� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT . <br /> _PERMANENT ❑ TEMPORARY 9NEW, IEsI REPAIR OTHER Vgk)V i 6E©, f? <br /> A <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site Q <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. a <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that tte work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and r ulati f the Joaquin"LoCal Health District. <br /> , APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> iBASE EXPLANATION BILLING REMITTANCE $ AM_ RUNT DUE CHECKED <br /> / DATE DATE REMITTED J/ AMOUNT <br /> FEE �Q <br /> LESS <br /> PRORATION <br /> l PLUS „ <br /> PENALTY - ..._. <br /> OTHER ry <br /> a <br /> OTHER - - - " rsri.. 4. <br /> �. - IsSuan a Date. Mailed <br /> Received by Date Receipt No. Deliv ed _. <br /> Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Boa 2009 STO KTON,C 95201 <br />