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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> .- APPLICATION t <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> S E PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> LIQUID WASTE 0 <br /> Application is he made to carry business in the jurisdictional area of the San Joaquin Local Health District 0 <br /> rBusiness Name A) Address <br /> N L <br /> i Owner Address <br /> a <br /> j Firm Partners, Ad resses and Telephone Number <br /> �- <br /> aBusiness Telephone No. ����7Eme�,gellyTelephone No. <br /> _J Contractor Licence No. <br /> Applicants Name (Print) Title —F�' .� Date <br /> Please check Applicable Category (1-7) and FIII in the Require Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �- <br /> E For July 1, June 30, 19� Disposal S7,@ („I <br /> Description(Make/Yr., Color) N <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. i <br /> Capacity Gal.,Weights & Measures No. _ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD N <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 1 R.S. or R.C.E. Name R.S. or R.C.E. No. <br />{ Test Location t Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location f <br /> zo'zet' <br /> Owner � Address <br /> I ❑ PACKAGE PLANT <br /> SEPTIC TANK CE SPOOL LEACHING FIELD SEEPAGE PIT <br /> PERMANENT ❑TEMPORARY NEW REPAIR OTHER AV <br /> I . CHEMICAL TOILETS For July 1, -Ju e 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 /> Where Certified <br /> Operator Name # � { <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> ❑ LAUNDRY For4Jul 1 -June 30, 19 r <br /> 7. LAUND y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <br /> Gly <br /> I hereby certify that I have`pre_pared this application and that the work will be hone in accordance with San Joaquin County <br /> I ordinance state laws, IP <br /> n'd'ru s and re ulatio the San Joaquin,Local Health District. <br /> APPLICANT'S SINATUREXya <br /> e- <br /> FOR DEPARTMENT USE ONLYF <br /> �• r <br /> Fee Is Due: 1:1 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑.Jant uary 1 &Received By January 3.1. :❑ July 1 &Received By July 31 <br /> � ! REMIT <br /> BASE EXPLANATION BILLING REMITTANCE" $ AMOUNT DUE CHECKED <br /> DATE , DATE! REMITTED > AMOUNT <br /> FEE S. �+�� <br /> k <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -`. <br /> 3 <br /> Received by Date Receipt No- Permit No. r ks uance le Mailed yere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O-Bo:2009 5KTON,CA 95201 <br />