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TileAPPLICHUO" <br /> Applications Will Be4Processed When Submitted Properly Completed. Be Sure ToSign <br /> -- APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPIAG <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Aoaqu <br /> pplication i ereby made to carry on business in the jurisdictional area of the Sanin Local Health District <br /> r i Address <br /> r a Business Name (D6 ) <br /> aOwner Address <br /> : Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. <br /> Contractor Licence No. <br /> Title _ Date <br /> Applicants Name (Print) <br /> Please check Applicable Category(1-7)and Fill in the Requi d Information <br /> 1. 11 PUMPER VEHICLE PERMIT'REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 ( Disposal Sites <br /> Description(Make/Yr., Color)! CAL. License Renewal No. <br /> Serial No. s CAL. License No. <br /> Capacity ' — Gala Weights &Measures No. <br /> Equipment Parking Address I <br /> 2. ElPUMPER YARD t <br /> For July 1, June 30, 19 !� ; <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored l <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> I Test Date/Time <br /> Test Lection f <br /> 4. LJ SANITATION PERMIT { u C <br /> Job Address/Location z- g y De".n - -� <br /> Owner <br /> .8. 04-Kdl F L Address <br /> C�1 C TANK ❑ CESSPOOL i LEACHING FIELD SEEPAGE PIT'S❑ PACKAGE PLANT <br /> ❑/ ❑ REPAIR ❑ OTHER <br /> PERMANENT ❑ TEMPORARY ❑ NEW w <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction Disposal Site <br /> I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 300, 19 Where Certified <br /> I Operator Name <br /> Plant Location ! <br /> No. Units Served �- <br /> I Plant Capacity xJ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t mak} y <br /> iww.a •r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rules d regulations of the San Joaquin Local Health.District. <br /> APPLICANT'S SIGNATURE X r ._ <br /> FOR DEPARTMENT USE ONLY 1 <br /> r <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $- AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> ' PENALTY <br /> OTHER <br /> OTHER <br /> DS <br /> Date Receipt No. Permit No, Iss ance D to Mailed Delivered <br /> Received by g,Hp LTON AV P.O.Box 2009 STOCKTON,CA 95201 <br /> 'APPLICANT-'RETURN ALL COPIES <br /> To; <br /> : ENVIRONMENTAL HEALTH PERMITlSERVICES' _f � n - <br />