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�— Applications Will Be Processed When Submitted Property Completea,tie bure I o alyr>, 6„e nyyuva.w,.. <br /> APPLICATION <br /> - - (For Non-Transferable,Revocable,and-Suspendable) 1. <br /> ENVIRONMENTAL HEALTH PERMIT SEPYAGE !! <br /> LIQUID WASTE 4. <br /> Application is hereb ade to carry on business in the•uri ictional area of the,8 Jo„ uin Local ti alth Distn t <br /> ,F Business Name (DBA) a � � Address ;r25 <br /> a Owner Address <br /> 9 <br /> M Bus ess Telephodne No. and T ; - Emergency Telephone No. <br /> TelephoneFirm Partners, <br /> Contractor Licence No. .......... �� ........ I <br /> .- r r Date <br /> LApplicants Name(Print) _' Title ____ <br /> Please check Applicable Category(1.7)and Fill In the Required ntormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) �r <br /> For July t, June 30, 19 Disposal SkesV <br /> ._..... <br /> Description(Make/Yr.,Color) <br /> Serial No. °O <br /> _ <br /> f CAL. License No. .... <br /> CAL_License Renewal <br /> � . <br /> -' Gal., $Wei hts&Measures No.,�:—�.-. - ' ...... <br /> Capacity --- - �•� ;..- _...•,..-• <br /> Equipment Parking Address t- ) -- vF <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 js <br /> i r' <br /> No.of Vehicles Stored 7 <br /> No.of Chemical Toilets Stored - -- , �• <br /> 3. ❑ PERCOLATION TEST -,-+•- <br /> R.B.or R.C.E.Name ft:S:�-or�R.C.E.No. _ <br /> It SATest Date/Time' <br /> Test Location <br /> 4.y NITATiON PERMIT § ,e -I /e, *� <br /> Job Address/Location._ �'' d <br /> . . Address <br /> Owner A <br /> 11 SEPTIC TANK ❑ CESSPOOL LLEACHING.FIELD WSEEPAGE PIT ❑.PACKAGE PLANT J,r <br /> J PERMANENT ❑ TEMPORARY O'NEW • I REPAiA A C7TtiER - <br /> ` 5- ❑ CHEMICAL TOILETS For July 1,,t June 30, 19 <br /> Type Construction ,. . ` ? ti Disposal Site—....... <br /> '' E4 ui mant Stora a/Cleanin Location(s) .......__. ' <br /> "• No.of Units "'" q p 8 •, g, r, _._._. ,......._. <br /> 6. ❑-PACKAGE TREATMENT PLANT For Juiyj,:-June 3019.--* <br /> ' Operator Name — , �> �•s•y Certified <br /> —- <br /> Plant Location <br /> Ptant Capacity n <br /> _ , NQ/Ur <br /> ed <br /> jt <br /> 7. ❑ LAUNDRY For July-1-June 30. ig <br /> SIZE: ❑ Less Than 1,000'aq: Ft.. 11More Than-1'000;8q::Ft. .� . <br /> r ❑ DRY CLEANING,Chemical5Lsed/AmoltntM4 `�i <br /> w E <br /> r/z -r-. <br /> ;�• i t INI <br /> I hereby certify that 'have prepared,his application and that tt+e work will be dohe,in accordance with San Joaquin County <br /> ordinances,stale laws and rules and,r_gulatlons ot`t San Jbagtf n LoGa{ Health District. <br /> � APPLICANT'S SIGNATURE X ; <br /> ! FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.£ACH ❑ January 1 8 Received By January 31 ❑ July 1&Receiyetl.9y July 31 <br /> — REMIT <br /> BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> „,. .DAT,EDAT•E faEMITSED,, �.. tx„ <br /> BASE EXPLANATION AMOUNT <br /> -- <br /> FEE �. <br /> LESS B <br /> PRORATION <br /> PLUS <br /> PENALTY _ = ..__ -•• <br /> I <br /> : OTHER ' <br /> 9 OTHER i s <br /> Received by Date Revel t No. ermit Na <br /> - e Oate fled r Dewered <br /> S'rOCKTON,CA S520t <br /> APPLICANT—RETURN ALL COPIES TO; E14VIRONMERTAL HEALTH PERMIT/SERVICES__ ��19C1 E.HAZELTON AVE,PO.Box 9009 ` <br />