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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable;Revocable,Iand Suspendable) SEETAGE <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 s r a <br /> rn <br /> ` pp <br /> Business f�llme ( )� Address <br /> K5" !, <br /> z Owners /Qf (DBA))r , Address x <br /> 1 Firm Partners, Addre es and Telephone Numbers w . <br /> a Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. I <br /> u Date <br /> �Applicants Name (Print) ,Title f <br /> Please check Applicable Category,(11-7)and Fill in the Requi d Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) --- <br /> For July-1, June.30, 19 Disposal Sites_. <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures'No. 1 <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD # t <br /> .For July 1, June 30,19 -t <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOL'ATION TEST <br /> R.,S. or R.C.E. No. <br /> R.S. or R.C.E. Name _ � <br /> Test Location Fr Test Date/Time <br /> t + � <br /> 4. Z-SANITATION PERMITS <br /> Job Address/Location �� dQ eft 6,a GV <br /> Address ) <br /> -Owner <br /> 1:1 SEPTIC TANK ❑ CESSPOOL- ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY 13 NEW REPAIR 13 OTHER E <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site -^–^w �—•ry - <br /> ft Equi meat Storage/Cleaning.Location(s) <br /> No. of Units P� ; . <br /> 6. <br /> 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name 11 <br /> Plant Location <br /> Plant Capacity m No. Units Served <br /> 7. El LAUNDRY For July 1,-June 30, 19 <br /> C <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq..Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo.i <br /> I hereby certify that I have prepared this application and t the-work will be-done I-1accordla ce with San-J a C ty (� <br /> Y p <br /> District.— <br /> ordinances, state laws, and r and egulations aft a San aquin Local Health Districts <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EACH ❑ January 1 &Received 13y January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BILLING , REMITTANCE AMOUNT DUE CHECKED <br /> BASF I EXPLANATION DATE - DATE. REMITTEb - - # - 'AMOUNT - <br /> FEE <br /> I S <br /> LESS <br /> > PRORATION - - - , <br /> PLUS <br /> PENALTY <br /> OTHER 'i - f-'" <br /> OTHER <br /> - Received by Date '.Receipt No Permit No. Issuance Date Mailed Delivered: <br /> 1641 E.HAZEL70N AYE.,P.O.Bol 2409 STOGKTON,CA95?41 <br /> APPLICANT—RETURN ALLCOPIEST0= ENVIRONMENTAL HEALTH PERMIT/SERVICES ' <br />