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Applications Will Be Processed WhenSubmittedProperlyr-amPwItru. OC --0- <br /> APPL1CATiCN <br /> (Far Non-Transferable,Revocable,and Suspendable) SEPPAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ade t arry usiness in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA)—Ire, Address — <br /> z Owner - _ Address_- <br /> a <br /> 0 Firm Partners, Addresses and Telephone Numbers - a, <br /> iBusiness Telephone No- - Emergency Telephone No. <br /> Contractor Licence No. .- - � <br /> Applicants Name (Print) <br /> Please check Applicable Calego ��6�- � Da <br /> Title -� — te <br /> ry(14)and Fifl in the Required 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. <br /> Equipment Parkin]Add ress� �_ - <br /> 2. ❑•PUMPER YARD <br /> For July�1, June 30, I'D <br /> No-of Vehicles Stored <br /> No-of Chemical Toilets Stored_ <br /> 3. ❑ PgRCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. — <br /> Test Latalivn s T4st Date/Tine <br /> 4. ❑ SANITATION PERMIT2 <br /> Job Address/Location <br /> Owner_ r Address— <br /> 10 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5- ❑ CHEMICAL TOILETS For July 1,-:tune 30,19 <br /> Type Construction Disposal Sito <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT for July 1 -,June 34,.19_, <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity. No.Units Served <br /> r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZF= ❑ Less Than 1,000 Sq- Ft., ❑ More Than 1,00d Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals UsedlAmounVMo- <br /> fiorneowacrcrlirsansndamnt'�si,nettseccWI't^ r - anrerfttieF>Ork'4r:rhich this rermilisissued,l shall nol employ any person <br /> ir,s-ich manllr•aS tr,yecarrte svb;t-T tl, <br /> ConTraa4::r'� >.zt17 nr pub carlYracta.;L, �._ c {� s isiswl.y: I cwtity that in the perlarma:iw of the Work far which this permit Isis sued,i shall <br /> employ persons 5uhj"l to warlcmali s 4 <br /> 1011,1d." <br /> A, _ <br /> hereby certify that I have prepared this application and that the work will be done in arcordance with San Joaquin County <br /> ordinances, state laws,and rules and Jlalions of the San Joaquin Local Health District. r � <br /> APPLICANT'S SIGNATURE x <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SI rE ❑ EACA _ ❑•January 1&Received t3y January 31 ❑ July 1 B Rece ved By July 31 <br /> - REMIT <br /> EASE EXPLANATION BIL LING REMITTANCE $ _ AMOUNT DUE CHECKED <br /> GATE DATE REMITIED AMOUNT <br /> FEE <br /> LESS <br /> PRDRAI ION <br /> PLUS <br /> ` PENALTY <br /> OTHER <br /> U rHER <br /> Received by Date Rcceipt No. Peirnii No 1 suance le Mailed Delivered <br /> APPLICANT—RETORN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMITlS£RVICES IS01 E.HAIELTON AVE.,P.O.eox 2009 STOCItTOH,CA 95201 <br />