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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) ?SA411 <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> LIQUID WASTE <br /> Appl is tion is her by made to carryon blasine n-the'urisdictional area of the San Joaquin Local Health District <br /> yBusiness Name n <br /> i Owner = 4_`�� ” Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> as Business Telephone No. # Emergency Telephone No. <br /> Contractor Licence No. .•1 <br /> OK <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7),-and Fill in the Required,Information,., <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 = Disposal Sites-Y - .T _ - ►1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal 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 I <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time x I <br /> 4. .SANITATION PERMIT <br /> Job Ad cess/Location , <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑';LEACHIN FIELD ❑ SEEPAGE PIT ❑ PA AGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER A6_*,doy, irq sgfic, �V1 k-, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 J 1 <br /> Type Construction - Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - <br /> Operator Name " ' Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 4, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ; <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hameowrwrar€?censer+agRnt'■signature 1rtifythatintheperforma"Ofthewaristorwhichthispermilisissued.Ishallnotemployanyper -n <br /> in such manner as to heL'0^;:'. Isili9Ct t�'.:'ir'.n,i.},. ,r,ny: rl^ntiil!1 1,-r4: <br /> Contractor's hiring or ub. cr.�,s n: ., .s ceiri#le' '+ =TallnVAD i coni,;'that i, the performance or the work for which this permit is issued,I shal <br /> i + emplay Persons subject to rro�klTu;n's CurT11,4 rt5:cuvs [aWs of C�silor7: .' u'° R r <br /> I hereby certify that"I have prepared this application and that the work will be done in accord n withajIP C unty <br /> ordinances, state laws, and rules and regulations of the San.Jo_aquin Local Health District. <br /> 'APPLICANT'S SIGNATURE X / s <br /> ¢. <br /> - FOR DEPARTMENUS <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ElE nuary 1 &Received By January 1 ❑ Juy 1 &Received By July 31 <br /> ft BILhE 't' <br /> ITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> _1 - - O •DATE REMITTED -- - AMOUNT <br /> + <br /> FEE DU �` O 6 <br /> ��^ d <br /> LESS <br /> PRORATION - - - - <br /> PLUS - <br /> PENALTY' i <br /> OTHER <br /> OTHER <br /> ! Received by Date 'Receipt No. _ Permit No, Issu nce Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON,GA 95201 <br /> t <br />