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Applications Wiil fie Processed When Submitted Properly Completed. Be SureTom1gn IFie ��SEPT'AGE <br /> APPLICATION(For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 0 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> " r Address <br /> y Business Name (DBA) <br /> Address 1 <br /> QOwner <br /> ,Firm Partners, Addresses and Telephone Numbers Emergency Telephone No- <br /> it <br /> o. <br /> L Business Telephone No. <br /> Contractor Licence No. _ Titleirnst Date <br /> LApplicants Name (Print) " - <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) g`\ <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Y_ r.,_Color) __, .__.. -. -- CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> - <br /> Capacity Gal., Weights &Measures No. <br /> -.. � <br /> Equipment Parking Address <br /> 2. '0 PUMPER YARD i <br /> For July 1, June 30, 1971 <br /> No.',of Vehicles Stored <br /> No. of Chemical Toilets Stored �F <br /> 3. ❑ PERCOLATION TEST • ; . R.S.-or R.C.E!No. 3 <br /> R.S'or R.C.E. Name' esDate/Time <br /> Test Location ;� J A*"e r&,V%: r , <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ' <br /> Address R <br /> Owner fl PACKAGE PLANT <br /> LEPTIC TANK ❑ CESSPOOL FIELD ❑ SEEPAGE t <br /> ❑ TEMPORARY AR .s* ❑ NEW =�— '�❑ REPAIR ❑ OTHER <br /> r ❑ PERMANENT - <br /> 5. ❑ CHEMICAL TOILETS For July 1,`-June 30, 19—.. , <br /> I Type Construction _pisposal•SiteL - - •; �. <br /> No. of Units --,Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAGE TREATMENT PLANT' For July 1, -June 30, 19 I Where Certified <br /> Operator Name <br /> Plant.t_ocation �y No. Units'Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: i ❑ Less Than 1,000 Sq. Ft., ❑ More Than,'1.,000 Sq- Ft.' f <br /> i, ❑ DRYSCLEANING, Chemicals/Used/Amount/Mo. , �^ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Joaquin Local Health District. <br /> ordinances, state laws, and rules and r iatio f the San <br /> .F i <br /> I <br /> V APPLICANT'S SIGNATURE X ` <br /> d,pr.Ciu..c.rw $�tM.� l.r- i,r,�FOR DEP R ENT E ONLY E_ <br /> -Fee Is Du ❑ ANNUALLY ❑ PER-UNIT PER SITE EACH January 1 &Received By January 31 July 1 &Received By July 31 <br /> ' REMIT <br /> 13ILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED ! AMOUNT <br /> 4pe <br /> r. FEE .'= vs <br /> LESS - <br /> -PRORATION <br /> PLUS" <br /> PENALTY <br /> OTHER r~ s <br /> j OTHER b j <br /> Permit No. Issuance tate, "� Mailed Deliver d <br /> Received by Date Receipt No. - <br /> TALHEALTH PERM x <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMEN1601E.HAZELTON AVE.,P.O:Box 2009 STOC ON,-CA 5201 <br />