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n Submitted Properly Completed. BeSure To Sign TheApplication. <br /> Applications W111 Be Processed WheF <br /> APPLICATION �1 <br /> i (For Non-Transferable, Revocable, and Suspendable) S7 PTAGE �� <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> LIQUID WASTE - ,,fin <br /> " Appli,ati i is ere made to�C rry on buss�s in the jurisdictional area of the San Joaquin Local Health District / <br /> �n Business Name DBA s - vv�f Address <br /> z Owner Address <br /> a <br /> u Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. _ �G� Emergency Telephone No. <br /> Contractor Licence No. <br /> �,, �,� Title Date _ <br /> L Applicants Name (Print) . <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites <br /> For July 1, June 30, 19 - Dis P <br /> Description(Make/Yr., Color) - _ <br /> CAL. License No`s- '� CAL. License Renewal No. <br /> Serial No. <br /> �.. <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 /> t; 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name � r <br /> _ Test Date/Time <br /> Test Location <br /> 4. )0 SANITATION PERMIT S n <br /> `-Job Address/Location _ <br /> Owner -�.r- i4 F^ Address <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD 20 SEEPAGE PIT LJPACKAGE PLANT Y <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER - r• <br /> 1 -5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 — Y <br /> 'Type-Construction . Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> t Operator Name <br /> Plant Location <br /> Plant Capacity - No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -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 /> 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X. <br /> FORED PARTMENT USE ONLY <br /> Fee_ Is Due: 11 ANNUALLY - ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEByl July 31 ' <br /> 3 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION "DATE DATE. REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Lo l,, <br /> OTHER <br /> —7—f�y <br /> f Ty�, b L ssuance Date ailed Delivered <br /> - Date i Receipt No. -•-s Permit No. I 7 <br /> Received by - <br /> APPLICANT—RETURWALL COPIES TO:,. -ENVIRONMENTAL HEALTH PPEERMI !SERVICES- '""s-"*-• 1601 E.HAZELTON AVE.,P.O„BOX 2009 ST ICKTONi C 952 <br />