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Y - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) _ o SEPI <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE" , <br /> Applical' is he made to carry o usiness int urisdictional area of the San Joa in cal Ith D r' <br /> NBusiness Name (DBA) ,Address r. I <br /> ~ 1 f Address <br /> a Owner a ,, F <br /> is <br /> Firm Partners, Addresses and Te ep one umbers <br /> Emergency Tele 9 y p <br /> a - hone,No. . <br /> a. Business Telephone No., e. <br /> Contractor Licence No. _ <br /> Date "+ <br /> dc <br /> Applicants Name (Print} _ Title , <br /> Please check Applicable Category.(1-7) and Fill in the Required'Information <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)' <br /> For July 1, June 30, i9. Disposal Sites.- - <br /> Description(Make/Yr., Color) - y•- •' ¢ <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> #'- <br /> Capacity ,_- Gal.,Weights & Measures No. w _ -� . _. _,_ l <br /> -(quipment Parking Address__ •+tr "�' <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,E-19<_t--t7n,3 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored P <br /> 3. ❑ PERCOLATION TEST 8 F ; ' { ef <br /> R.S. or R.C.E. Name RcS. or`R.C.E. No.' <br /> Test Location Test,U t/Time <br /> 4./KSANITATION PERMIT, <br /> Job Addres cation '' , 3 <br /> Owner— C.W .., Ad ress <br /> ❑ SEPTIC TANK ❑ CESSPOOL - LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT -- <br /> XiPERMANENT ❑ TEMPORARY ❑ NEW /REPAIR ❑ OTHER , <br /> 5. ❑ CHEMICAL TOILETS For.July 1, -June 30, 19— <br /> Type <br /> 9 Type Construction, 'Disposal Site <br /> No. of Units " EquIpment-Sxorag&/Clean inT..Location(s)`�` <br /> 6. ❑ PACKAGE TREATMENT PLANT ' For July 1, !"June 30, 19 `1` <br /> Where Certified <br /> Operator Name <br /> kk Plant Location + .7 <br /> Plant Units Served <br /> Capacity <br /> 7. ❑ LAUNDRY For July i, -June 30, 19 ""'"" ��? � t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,004 Sq. Ft. y <br /> ❑ DRY CLEANING,-Chemicals Used/Amount/Mo.", <br /> I hereby Gertify'that I have prepared this application and that the work will be done in accordance with an Joaquin County <br /> ordinances, state laws, and rules and rtguiations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> + <br /> iA <br /> ---FOA DEPARTMENT USE ONi_*1; Q`10 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑1AC11 ❑ January 1 &Received By January 31 0 July 1 &Received By July 31 <br /> _ REMIT <br /> BASE EXPLANATION ; BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r .. DATE DATE REMITTED AMOUNT <br /> FEE. <br /> i <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. :1Perrmt No.. �o �' Issu aryce tDta e Y Mailed Delivered <br /> I . APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICE5T`' <br /> —1:' A601 E� A2ELTON'AVe,P.O.Box 2009 STOCKTON,CA 95201 <br />