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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SLPTAGE <br /> LIQUID WASTE <br /> Application is ergby madam to carry on business in the jurisdictional area of the San Joaquin Local Health Diict <br /> w Business Name (DBA) �[, /��„/�C C le Address �lt Y 'tr` •� ` ` d <br /> a Owner��4,16l c' Address 0 l ,h�l�`—r <br /> 2 Firm Partners, Addresses and Telephone Numbers / 9 <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 0� Date <br /> Please check Applicable Category(1-7)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. Lic:::se Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Park ing.Add ress <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 <br /> Job Address/Locatpg4e_ L <br /> r Q ' <br /> Ow13.1 Address <br /> D SEPTIC TANK ❑ CESSPOOL ❑LEACHING FIELD 1:1 SEEPAGE PIT ` 13 PACKAGE PLANT <br /> 11 PERMANENT 11 TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regyjApbns ol the San quin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY JJ <br /> OTHER <br /> OTHER <br /> 637 3117-? 1B6 <br /> Received by Date Receipt No. Permit No. 11,Issuallice Date Mailedeliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 15201 <br />