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Applications Will Be Processed When SubAmPPLICAT1ONProperly Pletea rse sure .o oryl, • � ^rr <br /> � ! <br /> (For Nan-Transferable, Revocable,and Suspendable) SEi'TAGE r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ' oc III District <br /> ess in therisdictionall areeaofthe an JoaqulnL <br /> Applicatihereby�imadetocar onb nr Address <br /> . <br /> yBusiness Name (DBA) I`, Address <br /> a Owner <br /> 1 Firm Partners, Addresses and Tele one Numbers E�mergency Telephone No. <br /> I Business Telephone No. <br /> a <br /> Contractor Licence No. Date <br /> L Applicants Name(Print) II <br /> Please check Applicable C tegory (l`-7) and Fill in the Required Information <br /> �- ❑ PUMPER VEHICLE PERMIT,!`REGISTRATION (FOR EACH VEHICLE) ' <br /> June 30, 19 <br /> For July 1, Disposal Sites <br /> Description(Make/Yr., Color} CAL, License Renewal filo. <br /> Serial No. �CAL. License No. <br /> Gal.,Weights & Measures No, <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD Ili <br /> For July 1, June 30, 19' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST , ; R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name I ' <br /> Test Location I� � v <br /> VI Test Date/Time - <br /> 4. SANITATION PERMIT.' "Nib <br /> Job Address ocation r <<' <br /> I Address <br /> Owner �r L LEACHING FIELD ❑ SEEPAGE PIT ❑ P KAGE PLANT <br /> 11 SEPTIC TANK ,__,,,,�� 13 REPAIR OTHER S {� I'k y� kl�Xr` <br /> RMANENT MPORARY IE!'NEW <br /> #` 4 , <br /> 5 <br /> CHEMICAL TOILETS For,July 1,=June 30, 19 : N <br /> I .��I -. Disposal Site - <br /> /. Type Construction_ — _ <br /> No. of Units -ij Equipment'Storage/Clean <br /> Ing Location(s) <br /> 6. ❑ PACKAGE TREATMENT IILANT For July 1, -June 30, 19 _ Where Certified <br /> Operator Name <br /> I r� <br /> Plant Location No, Units Served 7q <br /> Plant Capacity <br /> 7. 11LAUNDRY For July 1;=rune 30, 19 <br /> SIZE: 11 Less Than 1,000 S111'Ft., ❑ More Than 1,000 Sq. Ft. <br /> 13DRY CLEANING,Chemicals hsed/Amount/Mo. <br /> lication an he work will be done in accordance with San Joaquin County <br /> I hereby certify that7i have pr ed this app- oa i District. F <br /> ordinances, state las, and and regul <br /> APPLICANT'S SIGNAT i t <br /> FOR DEPARTMENT USE ONLY <br /> E ❑ EACH b❑ January 1 &Received By January 31 ❑_ Ju'ly 1 &Received 8y JuVy 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE REMIT <br /> i. ,BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE REMITTED AMOUNT <br /> BASE DATE r_ <br /> I FEEAc <br /> PRORATION <br /> PLUS !Illi r <br /> PENALTY IIp!! <br /> OTHER <br /> OTHER <br /> �I�� Issuance Dale f Mailed Del' erect wM <br /> bReceipt No. Permii No. <br /> � <br /> Received by pp ate 1641 E.HA2ELTON AVE.,PO.Box 2409 ST CKTON, 95201 <br /> APPLICANT—RETURN'ALL:60PIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - - <br />