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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> APPLICATION �r <br /> (For Non-Transferable, Revocable, and Suspendable) S�pTAGE 1� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ° I <br /> Application i pereby made to carryon business i the'urisItctional area of the San Joaquin Lgjpal Health District <br /> o . <br /> HBusiness Name Address �'l� 7 cam` <br /> aOwner Address <br /> V Firm Partners, Addresses and Telephone Numbers >; <br /> Emergency Telephone No. <br /> a. Business Telephone No. <br /> j Contractor Licence No.. <br /> Applicants Name (Print) - ' °`� "� Title Hate <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Sites <br /> For July 11 -v�June 30, 19 Disposal I <br /> Description(Make/Yrti Color) <br /> .. CAL. License No. CAL. Licc ase Renewal No. <br /> Serial No. <br /> Capacity " ' *.° k 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. 11 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Testt�Test Date/Time <br /> ation " <br /> 4. SANITATION PERMIT ' <br /> 1, Job Address/L tion <br /> jr <br /> Owner Address <br /> Ii. ❑ SEPT[ TANK ❑ CESSPOOL ,LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY '❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-r une 30, 19 <br /> Type Construction 3 Disposal Site <br /> No. of Units ` Aj '+ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name' <br /> Plant Location =fir <br /> Plant Capacity `t No. Units Served <br /> 7. ❑ LAUNDRY For July•1 =June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., Cl 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 andregul tions of the San Joaquin Local Health District. <br /> JC .. <br /> APPLiCANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LrPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LlS y t/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 17 CDC3 <br /> I Date Receipt No <br /> Permit No. Is uance Date Mailed D livered <br /> Received by 95201 <br /> - � APPLICANT—RETURN ALL COPIES TO: � ENVIRONMENTAL HEALTH PERMITlSERVICE�'�����ZE�ON AVE,P.O.Box �STOCK��CA � i <br />