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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i _ 3 APPLICATION <br /> / (For Non-Transferable,-Revocable,and Suspendable) S PTAGE <br /> f� ENVIRONMENTAL HEALTH_ PERMIT <br /> LIQUID WASTE <br /> Application is eby made arry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> F Business Name (DBA +� Address r <br /> a Owner { : .: Address- <br /> • Firm Partners, Addresses and Telep one Numbers <br /> aBusiness Telephone No. ��' Emergency Telephone No:4 <br /> Contractor Licence No. <br /> :. t Applicants Name (Print) µ Title ; Date . -- <br /> �' Please check Applicable Category (1-7)and Fill in the Required Information .r , ;i •, r _` �gr;3 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, --June 30, 19 Disposal'Sites _ <br /> a Description(Make/Yr., Color) r <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 r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E.No. <br /> Test Location 4 Test Date/Time <br /> 4. ❑ SANITATION PERMIT I� / <br /> Job Address/Lo t' LJ <br /> Owner Ia Address <br /> ❑ SEPTIC TANK C❑ CE OOL ► EXLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY t 11NEW REPAIR ❑ OTHER <br /> S. 13CHEMICAL TOILETS For July 1, -June 30, 19 `. <br /> Type Construction Disposal Site -� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT p For July 1, -June 30, 19 <br /> Operator Name Wherte Certified <br /> Plant Location ) <br /> —4 <br /> Plant Capacity _ } No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-.June 36, '19 <br /> SIZE: ❑ Less Thanr1;000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. -� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. —� <br /> q+tt I' tucrtify <br /> I{ame oWngror Is t t e C c suq#ec�to ti c tetra?fl cothe <br /> . nsafe'I �:s of Cali!hrat3ia the�tif f that ir1 ttse perterr anceyo lthe vorrk tot which this permit is ch th Per+tt1+1 Fs issued.I she ll AM tmPIOY 0 <br /> in such manner a <br /> Contractor's hirin or gub-ccitrCciing ,sync;,Mre cern ie= ri follgwing: CC !F t <br /> f empl persons subYlect to warkntati s cm1=.Pansatien lases vi Cc;iiornia.' If <br /> °Iyereby certify that;I have prep this application and that the work will be done in accordance with San Joaquin County <br /> ordinances„state laws, and rule regulat' ns oft San Joaq 'n Local H Ith Dista - <br /> APPLICANT'S SIGNATURE X I <br /> i _. t.... .FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> �J I — <br /> BILLING REMITTANCE $ - REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REKfITTED- <br /> I AMOUNT <br /> Lit_5 <br /> FEE a g <br /> =s � 4. <br /> LESS ' <br /> PRORATION <br /> r PLUS <br /> :.OTHER a r <br /> OTHER �' N <br /> r <br /> X535 l` <br /> Received by Date Receipt No. Permit No, Issuarice Date Mailed Delivere <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKY N,CA 95201 <br />