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M Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTneAppilCanon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) + <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is, ereby ode to rry on usiness' t e jurisdictional area of the San Joaquin Local Health District <br /> Addrq <br /> N Business Name (DBA) <br /> z Owner Address <br /> a - - <br /> J Firm Partners, Addresses and Telephone Numbed ` ► <br /> IL Business Telephone No. ((��,, Emergency Telephone No. <br /> a <br /> Contractor Licence No. _ <br /> Title Date <br /> 3 <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the equired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. _ <br /> i <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 7Vt <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> { � r <br /> R.S. or R.C.E. Name } A <br /> Test Date/Time <br /> Test Location 1 <br /> 4. SANITATION'PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ��y ❑ PACKAGE PLANT `�• <br /> IfCJ SEPTIC TAMC CESSPOOL LEA iNG FIELD ❑❑ SEEPAGE <br /> E PIT ❑ OTHER <br /> Iia PERMANENT ❑ TEMPORARY '2NEW <br /> l 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> fType Construction Disposal Site <br /> No. of Units Equipmenk Storage/Gleaning Location{s) F �� <br /> 6. ❑ PACKAGE TREATMENT PLANT -.For July 1, -'June 30, 19 1 <br /> k<�; '! Where Certified `` : <br /> Operator Name <br /> Plant Location <br /> " ?W No. Units Served <br /> Plant Capacity <br /> T. ❑ LAUNDRY--For July,1, —June-30,.1:9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. .` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � <br /> I { <br /> I hereby certify Iyhave pared this application and that the work will , _done in accordance with San Joaquin County <br /> ordinances, state laws,'an rul s and regulations of the San Joaquin Locaealth District. <br /> APPLICANT'S SIGNATURE X x <br /> FOR DEPARTME T Sr- LY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT PER SITE ❑ EACH January 1 R Received By January 31 ❑ July 1 &Received REMITBy u y 31 <br /> " ILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> . BASE- EXPLANATION DATE DATE REMITTED AMOUNT s <br /> FEE <br /> ' LESS : <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> I , <br /> OTHER <br /> OTHER <br /> x d 31 -7 <br /> = e- - <br /> i 1 - Perm' N.O. } Issry�ance Date Mailed Deliver <br /> Received by ,.`- Date - - eceipl No. - - <br /> 1601 E.NAZELTON AVE.,P.O.Box 2009 STOC 0 A <br /> APPLICANT-RETURN ALL COPIES TO:"' ENVIRONMENTAL HEALTH PERMITISEAVICES - <br />