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IC L;omPLtf&=+. .+ <br /> _- --g --- <br /> d Properly <br /> Applications Will Be Processed When SuAPPLICATION <br /> .a: SE PTAG E <br /> (For Non-Transferable,Revocable, and Suspen EALTH PERMIT <br /> ENVIRONMENTAL HT <br /> LIQUID WASTE <br /> hereby made to carryon business in the jfisdictional area of the San Joaquin Local Health District <br /> Application is h Y e _ N�- Address j <br /> hBusiness Name (DBA) Address <br /> ' a i� <br /> ? Owner �S'� <br /> a Emergency Telephone No. <br /> Lr <br /> Firm Partners, Addresses and�e bone Numbe _ <br /> a -Telephone No. c/ a Date <br /> Contractor Licence No, Title <br /> Applicants Name Name <br /> (Print) ~ �] <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1 ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOREACH <br /> V HICLE) <br /> i For July 1, June 30, 19 <br /> Disposal f CAL. II Renewal No---------------- <br /> i Description(Make/Yr.,Color) CAL. License No. <br />! Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> I Equipment Parking Address <br /> 2, ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> F No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> I Test Location <br /> 4. ❑ SANITATION PERMIT C t SG D <br /> 1114! 7 77; ✓ <br /> Job Address/Location ra Address 4� U. PACKAGE f LAN <br /> Owner -'�f" SEEPAGE PIT <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD❑ NEW ®' ❑ OTHER <br /> REPAIR <br /> 11 PERMANENT C3 TEMPORARY <br /> 4 ti 4` <br /> 5 ❑ CHEMICAL TOILETS For July 1,_June 30, 19 <br /> Disposal Site ) <br /> Type Construction Equip <br /> ment Storage/Cleaning Location(s) C� <br /> No. of Units <br /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> r <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity , <br /> 7. Cl LAUNDRY For July 1, -June 30, 10 <br /> More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> E ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t �I1i <br /> have re ared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that 1 P rep <br /> state laws, d rules and r'gulatio. of t139--Sp Joaqui Local Health District. <br /> ordinances, <br /> APPLICANT'S SIGNATURE X . <br /> ) <br /> C)6 - <br /> I FOR DEPARTMENT USE ONLY . <br /> ❑ _January 1 Is Received.By January 31 ❑_ July 1 &Received By July 31 <br /> I -- REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EACH REMITTANCE AMOUNT DUE CHECKED <br /> BILLING ,REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION } <br /> PLUS Y* <br /> PENALTY <br /> OTHER �. r <br /> OTHER _ • [' .q i ^� <br /> O 3-?`'-fTJ 8e MalCA 95201 <br /> ed Deliveredd STOGKTONdl+ <br /> Receipt No Permit No. - <br /> Received by Date 1601 E.HAZE VE.,P.O.Box 2009 . <br /> .APPLICANT—RETURN ALL COPIES TO: ENYIRONMENTAL;HEALTH PERMIT/SERVICES <br />