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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SE€'TAGE <br /> LIQUID WASTE <br /> Applicatj is hereby mad to carryon business in the jurisdictional area of the San Joaquin cal Hea h riot <br /> ,�Business N e (DBA) A-ddres a s <br /> IP- <br /> Owner Address Q 45, <br /> I <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CIL <br /> Business Telephone No, G 1 _ Emergency Telephone No. J' <br /> -J Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Requir d Inlormalion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, License Renewal No. � s <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 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 /> �i <br /> 4. .ff SANITATION PERMIT <br /> Job Addre s/ ocation <br /> Owner ` "tom Address Q <br /> ❑ SEPTIC TA ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW X REPAIR OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 n <br /> Type Construction Disposal Site S <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified �• <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> I` 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> `A <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �r <br /> C <br /> a <br /> i I 'hereby certify that I hav red this application and that t e work will be done in acco dance with S oaquin County <br /> ordinances, state laws, �d r les d regulations of he San Joa u' Local Health District. <br /> APPLICANT'S SIGNATURE X VA <br /> ` � 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is'Due: ❑ ANNUALLY ❑ PER UNIT R PER SITE ❑ EACH ❑ Janua R eive By nuary 31 ❑ July 1 &Received By July 31 l <br /> REMIT <br />' BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> j DATE DATE ITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> �i PENALTY i <br /> OTHER <br /> OTHER <br /> Dom- -z� <br /> Received by Date Receipt No. .Permit No. Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH-PERMIT/SERVICES -16D7 E.HAZELTON AVE.,P.O.Box 2049 STOC TON,CA 95201 ; <br /> i <br />