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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppllcauon. <br /> APPLICATION <br /> «• (For Non-Transferable;Revocdble, and Suspendable) <br /> S E PTAGE <br /> ENVIRONMENTAL HEALTH!P.ERMIT <br /> LIQUID WASTE <br /> Application is h by mady to arty op bu es s in the j 9sdictional area of-t�}jSan. aquln Local Health District <br /> HBusiness Name'(DBA) Address• ��• - ��: I <br /> i Owner:, Address _ <br /> Firm Partners, Addresses and Telephone Numbers <br /> aEmer enc Telephone No. <br /> M Business Telephone No., .• .. fQ 1 _ ,, g Y <br /> a - <br /> 1 Contractor Licence No Z <br /> L Applicants Name(Print) r } d _ Title _ Date.. <br /> r <br /> Please check Applicable Category (1,7)--and Fill in the Required Information • ,, } <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> D osal'Sites <br /> For July 1; P <br /> Description(Make/Yr:, Color) <br /> Serial No. f C. Z CAL. License No. CAL. License Renewal No. I <br /> Capacity •3''"-Gal.,11Veights & Measures No. <br /> i <br /> Equipment Parking Address �' r <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30;19 - t <br /> No. of Vehicles Stored 4 ; <br /> No. of Chemical Toilets Stored s <br /> 3. -❑ PERCOLAI'•ION TEST i <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> f ( <br /> Test ocation t ;Test Date/Time r <br /> 4. Kj SANITATION PERMIT <br /> Job Address/Location CQ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL EACHING FIELD %SEEPAGE PIT PACKAGE PLANT. <br /> 11 PERMANENT <br /> C] TEMPORARY -- :❑ NEW iEPAIR ❑ OTHER s r } <br /> 5. 11CHEMICAL TOILETS For July 1, -June 36, 19 <br /> Type Construction # Disposal Site" t. <br /> E'ui ment n Stora a/Cleani 'Loc ation(s) ` <br /> No. of Units q P 9 _9 <br /> " tt <br /> 6. El PACKAGE TREATMENT PLANT ;For July 1, -June'30, 19 "` t <br /> Where Certified, <br /> O ' - <br /> peratorName <br /> \ <br /> Plant Location i+ <br />` plant Capacity fl 1 No. Units Served <br /> ,t <br /> r 7. ❑ LAUNDRY For Julyrl, <br /> ❑ -June 30, 19 z x <br /> F �. <br /> SIZE: Less Than 1,000 Sq�. Ft., ❑ More Than 1,404 Sq.-Ft. 1� � m �:_ '; <br /> ❑ DRY CLEANING, Chemicals Used/Amaunt/Mo'� <br /> linrne ow�ier orncensedsgn,rt s signature certtf#ae it�e tbtTawtng:"I rnrtttV lhafi iA fheper€Otm anceof the work fpr WN0 this permit is issued,l stfall not employ an r <br /> F I "h T?Afir"}L:aa-_5'o becom@ 5;?;y;QL1 tC,W0rkmai c n 's'i ! ;4. .. - . , <br /> Cfrtiv -';r FCifC�YYi:t(�; i C@rii;L it!:':':`ti�"��'I� t14��^f:i IIIc`,vO rn for which fhis,P'6 111151551:C,`'.••15i r` <br /> itiliSSL' ,.^.Iln :^r..,:;..;i <br /> I hereby certify that I have prepared this application and that the;work will be done in on ' with San Joaquin Coun(yw <br /> ordinances, state laws,.and rules and.rsgulati. s of the ­j <br /> F oaquin Local Health District. 9 - ' . <br /> APPLICANT'S SIGNATURE X _ <br /> OALe— <br /> ray t <br /> �,.. 1 ! t <br /> r... FOR DEPAFTMENT;USE ONLY- - '—T <br /> } _ ". . <br /> t Fee IS Due: ❑ ANNUALLY ❑ PERUNIT; ❑_ PER SITE,- ❑ EACH _ ❑ January 1 &Received By January 31 ❑ July 1,&Received By July'31 . <br /> _ REMIT <br /> BASE - EXPLANATION `BILLING �: REMITTANCE $ AMOUNT DUE CHECKED t, <br /> kp DATE DATE REMITTED AMOUNT <br /> 4 FEE <br /> $ LESS <br /> PRORATION - <br /> ' PLUS - <br /> PENALTY F <br /> i OTHER <br /> _ OTHER .- - - - - <br /> Recerved by - Date iReceipt No. Permit No lssu a Dat Mailed Delivered <br /> h <br /> APPLICANT—RETURN ALL COPIES TO: ENYIRONMEN7ALHEALTH PERMIT/SERVICES` 1601E.HAZELTON AYE.,P.O.Box 2009 STOGKTON,GA 95201 - <br /> i I <br />