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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPL,1CATI ON <br /> (For Non-Transferable,Revocable,and Suspendable) SFPTAGE , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the� u L al HHe t b tr'c� <br /> f Business Name(DGA) Address �" Ipop <br /> 7 <br /> z Owner Address <br /> U Firm Partners,Addresses and Telephone Numbers <br /> a Business Telephone-No. V Emergency Telephone No. , <br /> { <br /> Contractor Licence No. -i�lDate <br /> L Applicants Name(Print) +���^ ems. Title <br /> Please check ApplicableCategory(1-7)and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT,OEGISTRATION(FOR EACH VEHICLE) <br /> For July 1, . June 30, 1i9 — Disposal Sites _ <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. 11 CAL License No. <br /> Capacity 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, ❑a PERCOLATION TEST <br /> R.S.or R.C.E.No. <br /> R.S.or R.C.E. Name <br /> Test Location iN Test Date/Time <br /> 4. 16 SANITATION PERMIT �� r <br /> Job Address/Location rt <br /> Owner !� Address <br /> X SEPTIC TANK 1 CESSPOOL LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ( ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS Fo6uly 1,-June 30,19 _ - <br /> 1 ype Construction Disposal Site <br /> r No.of Units . Equipment Storage/Cleaning Location(s) Q <br /> •6. ❑ PACKAGE TREATMENT PLANT For July 1,-.lune 30, 19 <br /> IjJ Where Certified <br /> Operator Name <br /> Plant Location - <br /> 1 No.Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY. For July 1;-June 30, 19 =" <br /> SIZE: ❑ Less Than 1,000 Sq_ Vit,, ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Nio. I "� <br /> I I hereby certify that I lave prepared this applica#ion and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,'.n les and regulations of the-San aquin Local Health District: <br /> APPLICANTS SIGNATUREX I� <br /> FOR DEPARTMENT USE ONLY + <br /> Fee IS Due: ANNUALLY I ❑ PER UNIT ❑ PER SITE El EACH ❑ January I&Received ey January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTEDT j( AMOUNT <br /> 5 <br /> FEE <br /> LESS <br /> rF PRORATION - <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> F OTHER <br /> Permit No. }ssuan a Dale Mailed. . pglivere0 <br /> Received'by Date' Receipt No, . <br /> t pPPLJCANT—RETURN"ALL COPIES To.. ENVIRONMENTAL HEALTH PE:RIi11T1SERYICE$ ,, teat E;►{A2ELTQN AVE..PA..Box 2009' STQCKT !i,CA 85201 <br />