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Applications Will Be Processed When SubmittedProperly Gompieiea. oeturc •v .,,y,• �r <br /> "--APPLICATION <br /> -• - (For Non-Transferable, Revocable, and Suspendable) SE.PSAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA) Address <br /> zOwner =Address <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. sr <br /> Applicants Name (Print) Title — Date <br /> Please check Applicable Category(1-7) and F111 in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` <br /> For July 1, June 30, 19 Disposal Sites <br /> Descriptiors(Make/Yr.,Color) <br /> Serial No. <br /> t CAL. License NO. CAL. License Rencwal No. <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 O <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. IR SANITATION PERMIT /1 J � <br /> Job Address/Location CSL (� <br /> Owner if Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Z SEEPAGE PIT PACK <br /> RR <br /> GE PLANT <br /> 15 PERMANENT ❑ TEMPORARY NEW 11 REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name I <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Fl. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in ac br c with San Joaquin County <br /> ordinances, state laws, and les and regulations of the San Joaq n Local Health District. 1� <br /> APPLICANT'S SIGNATURE X L <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT L8 PFR SITE ❑ EACH ❑ J ary eceived By January 31 ❑ Juiy 1 &Receiv.dEB'yl July 31 <br /> A <br /> BASE EXPLANATION BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> 1,'DATE D E REMITTED AMOUNT <br /> I r <br /> D to Receipt No. Permit No. Issuance Date Mailed Delle red <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH RMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Box 2009 $TO KTON,GA 5201 <br />