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Applications Wilk Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPPAGE <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> i LIQUID WASTE <br /> Application,is hereby made to carry on business in the jurisdictional area of the.San-J aquin Local Health District <br /> rn Business Name (DBA) r4n'%jyd^' - _ Address <br /> aOwner - — Address.. .._ s . .. .. . <br /> 1 Firm Partners, Addresses and Telephone Numbers - <br /> a Business Telephone No.. f "-Emergency Telephone No. <br /> �j Contractor Licence Na. E <br /> �Appkicants Name (Print) ��- i Title �.0.��" 7 Date V— 1511, . <br /> r <br /> Please check Applicable Category (1-7) and Fill in the Required Information t°z > <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.. V CAL. License Renewal No. <br /> Capacity' Gal.,-Weight's & Measures No. <br /> Equipment Parking Address'{--- <br /> 2. <br /> ddress'{`^2. ❑ PUMPER YARD 1 <br /> For July 1, June 30;19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 4 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/Location C3 (� <br /> O.wne �'�� Address r�19/ F <br /> I!d'SEPTIC TANK' ❑ CESSPOOL LEACHING FIELD :0 SEEPAGE PIT ❑ PACKAGE PLANT '�° <br /> ❑ PERMANENT ❑ TEMPORARY` EW ❑'REPAIR OTHER ? <br /> a <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30-197 <br /> Type Construction Rif - € f <br /> Disposal Site <br /> E - No. of Units Equipment-Storage/Gleaning-+-ocation{s) - <br /> r• < J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t411 <br /> Operator Name Where Certified <br /> Plant LocationF 'f r <br /> Plant Capacity No <br /> 7. ❑ LAUNDRY For'Jly-1 +�nez30,-19 <br /> y. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More`Than 1,000 Sq.'Ft. yr <br /> © DRY CLEANING, Chemicals Used/Amount/Mo <br /> I hereby certify that I have prepared 'th1's application and that the work will be done in accor'd'ance with Sarn'Joaquln County <br /> ordinances, state laws, and rules andre ation of the San Joaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE X <br /> FOR,1 EP..ART.MENT 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 /> s - t - -- I REMIT, <br /> 'BASE EXPLANATION =¢BILLING REMITTANCE,' $ AMOUNT DUE, CHECKED <br /> V-DATE DAT REMITTED - AMOUNT <br /> FEEqs <br /> A. <br /> �. <br /> LESS Y <br /> 9 <br /> PRORATION­ 4- <br /> i <br /> l PLUS <br /> ' .PENALTY <br /> OTHER '- -. _ •t-� e .:- f 3 ` t <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201" <br /> 3 <br />