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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> r. APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEEPAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio 's hereb made to carryo business in the jurisdgional area of the San Joaquin Loyal Health D rict <br /> rn Business Name {DBA) Address ' 1Pc d�/ <br /> II- Owner %Jd Z- Address <br /> 9 Firm Partners, Addresses and Telephone Numbers r <br /> aBusiness Telephone No. Emergency Telephone No. ";- <br /> Contractor Licence No. a <br /> Applicants Name (Print) ►� Title ��' Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 .{ Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. t 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 /> r No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST' <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> t. <br /> Test Location Test Date/Time <br /> k 4. ❑ SANITATION PERMIT <br /> Job Address/Location / '" V70 <br /> Js~ ° <br /> Owner ►� � '°'S Address j � - <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT [].TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> IF C.IQ <br /> 5. ❑ CHEMICAL 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 For July 1, - June 30, 19 <br /> Operator Name Where Certified �J <br /> l Plant Location <br /> Plant Capacity I 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 /> fl <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k <br /> I hereby certify that I h e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, n rules'an gulat'o s of n Joaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> `{S Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ©January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> € BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> _ DATE DATE REMITTED AMOUNT <br /> � eC7 <br /> FEE 4S' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER *o <br /> OTHER <br /> 2- <br /> Received by Date Receipt No. Permit No. Iss nee ate Mailed Deiivered <br /> - APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E: AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br /> 6. r� <br />