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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) I <br /> ENVIRONMENTAL HEALTH PERMIT sEPrAGE <br /> LIQUID WASTE <br /> Application is here y made to carry on business in the jurisdictional area of thee San aquin Local Health District <br /> H Business Name (DBA) ��'� Address �D' l� /�15� �_ 9S'Z0 / <br /> aOwner ( Address <br /> Firm Partners, Addresses and Telephone Numbers Qb <br /> CL <br /> Business Telephone No. —9,e-p 7 Emergency Telephone No. JS <br /> Contractor Licence No. Z 5 — - } <br /> Applicants Name (Print) � � Title �e$7 Date — z <br /> Please check Applicable Category (1-7) and Fill in the Required Information i <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 Parking Address <br /> I� 2. ❑ .PUMPER YARD <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored <br /> r No. of Chemical Toilets Stored -. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name f R.S. or R.C.E. No. <br /> Test Loci Test Date/Time <br /> 4. Sb ANITATION PERMIT <br /> Job Address/Location �PS�S �/D A4P4A1r-.[1C c.;' STCA4) <br /> Owner pi���!- �K /l/.c�.� . 1 — Address F�"r ?�1���Q/,car / ���� "C4 <br /> I�5 PTIC TANK 11 CESSPOOL O LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> IJ PERMANENT ❑ TEMPORARY 9-NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site 4 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> H .A . c7 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ( Where Certified A <br /> i 5 <br />` Plant Location ^ <br /> _ b <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,-19 <br /> SIZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />' F <br /> 1`u Y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County !� <br /> ordinances, state laws, d rules ancjelegulationp of the an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 6419b F 04 <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Sw� <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT r ❑ PER SITE- ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE - EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ? <br /> PRORATION <br /> PLUS } m a <br /> PENALTY • - <br /> OTHER Kid <br /> OTHER r <br /> 5� c5 3 o "a <br /> Received by Date Receipt No. Permit No IlisuanceliDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009- S_TOCKTON,CA 95201 - .� <br />