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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign 1neAppircatrIurr. <br /> APPLICATION ti r <br /> - `� (For Non-Transferable, Revocable,and Suspendable) <br /> SEP7AGE r <br /> ENVIRONMENTAL HEALTH PERMIT t7 <br /> LIQUID WASTE Q 2-'s— 4ZC7—A Y <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) ` Address <br /> z Owner Address 4 r <br /> d <br /> Firm Partners, Addresses and Telephone Numbers <br /> �����o Emergency Telephone No. <br /> a Business Telephone No. II r <br /> a <br /> Contractor Licence No. — <br /> a �.�, Title E 7' Date 1— <br /> & <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> u <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites « <br /> Description(Make/Yr., Color) <br /> GAL. Lic Ise Renewal No. <br /> CAL. License No. p <br /> Serial No. I <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 s <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST :Ir <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name 11 <br /> Test Location Test Date/Time R <br /> l 4. 14 SANITATION PERMIT IM <br /> WAS r- c' <br /> Job Address/Location ,' <br /> Owner A01 Address <br /> I SEPTIC TANK C3 CESSPOOL LEACHING FIELD 11 SEEPAGE PIT 13 PACKAGE PLANT li a <br /> PERMANENT <br /> ❑ TEMPORARY IN NEW ❑ REPAIR ❑ OTHER !I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 II 6- <br /> ii <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> p , <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Where Certified F <br /> Operator Name i <br /> Plant Location !° <br /> No. Units Served ° <br /> r Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ° <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- I' ` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and t e rk will be done in accordance with San'Joaquin County <br /> k ordinances, state laws, and rules and regulatio of the San Joaquin ocal Health District. <br /> I APPLICANT'S SIGNATURE <br /> .F <br /> FOR DEPARTMENT USE ONLY Il <br /> Fee IS Due: ❑ ANNUALLY- ❑ PER UNIT El PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received Byl July 31 <br /> + BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED i AMOUNT <br /> FEE <br /> LESS L <br /> PRORATION <br /> PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER II ` <br /> 0 3 s`77 i <br /> Receives uy-' nate Receipt ryu. Permit No. <br /> Issuance Date Mailed $ eliver <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 A 95201 <br /> ` STOCK ON,C <br /> E <br />