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Applications.Will Be Processed When Submitted Properly Completed, BeSureto sign Inemppirtnuan1. <br /> �. APPLICATION <br /> {For Non-Transferable;Retiocable;and Suspendable) SEpTgG <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ly made to ry o b ness in the jurisdictional area of tl� n lo`quip i�-ealthtrigt_ � 3z� <br /> Address <br /> rBusiness Name (DBA) <br /> a Owner .II" <br /> Address n <br /> J Firm Partners, Addresses and Tele"h a Num rs <br /> No- <br /> IL Business Telephone No. i Emergency Telephone No. <br /> IL _ <br /> Contractor Licence No. pate �' ~ <br /> Applicants Name (Print) iAnl Title. <br /> Please check Applicable CategoryF,(1-7,) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,- June 30, 19 Disposal Sites . <br /> Description(Make/Yr., Color) IM <br /> Serial No. <br /> I� CAL. License No. CAL. License Renewal No. <br /> Capacity ' wM Gal.,Weights &Measures No. <br /> Equipment Parking Address �N _ <br /> 2. ❑ PUMPER YARD 4 •- <br /> .Fol'�?luly�1, ^ `\ Jun"l 19 <br /> No. of Vehicles,Stol <br /> No. of Chemical jT ilets Stored <br /> ll� � <br /> 3. ❑ PERCOLATION TEST I� R.S. or Pill No- <br /> R.S. or R.G.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4: ❑ SANITATION PERMIT I�I' <br /> Job Addr s/Location <br /> Owner _ Ad ress <br /> t LEACHING FIEI ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK O'CESSPOOL r OTHER L��1C�C�]C �l.St��o+� <br /> ❑ PERMANENT TEMPORARY <br /> ❑ NEW REPAIR <br /> 5. ❑ CHEMICAL TOILE F uI�I July�1;�June 30, 19 d <br /> Type.Constroctii0 I - Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19. — , + <br /> NN Where Certified <br /> Operator Narrie., <br /> Plant Location <br /> Plant Capacity_ f.. >> s +.4 �No. Units.Served <br /> • • '�" -« <br /> 7. ❑ LAUNDRY For July 1, -lune 30,-19 t <br /> SIZE: ❑ Less Than 1,000 Sg1l., ❑ More Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law an rules and re lations e�San Joaquin Local Health District.' <br /> I11 <br /> APPLICANT'S SIGNATURE X ry <br /> I = <br /> FOR DEPARTMENT USE ONLY- <br /> 731 <br /> NLY- i <br /> Fee Is Due: ❑ ANNUALLY.;� El PER UNIT - ❑ PER SITE ❑ EACH _ ❑ January 1 &Received By January 31: El July l &ReceivedREMITBy uIy 31 <br /> I� BILLING - REMITTANCE $ $ AMOUNT DUE CHECKED <br /> BASEEXPLANATION DATE DATE iREMITTED AMOUNT <br /> Ip �q' <br /> FEE Y <br /> F <br /> LESS I� <br /> PRORATION <br /> PWS it <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> Received by <br /> Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br /> R601 E.HAZELTON AVE.,AYEP.O.130 2409 "STOGKTON,GA 95201 <br /> APPLICANT—RETURN ALL PIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4, 1a 3 - - <br />