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Applications Will B. ;ed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> R APPLICATION <br /> �,r Non-Transferable, Revocable, and Suspendabl,__,. $Ep AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is here made to arty On business in the jurisdictional area of the an Joaquin Local He <br /> til alt District <br /> y Business Name (DBA) Address •0 <br /> aOwner Address <br /> Firm Partners, Addresses and T lephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No: <br /> Contractor Licence No. - <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) _ ,..� <br /> Serial No. CAL. License No. CAL. License Renewal NO.` <br /> Capacity Gal., Weights & Measures No. 4 <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 Test Date/Time <br /> 4. ©-%ANITATION PERMIT <br /> Job Address/Location "T A.,-' <br /> Owner__ 7_e7 Ir -,� Address. s-W <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2-fEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT ..... <br /> '©"PERMANENT ❑ TEMPORARY . ❑ NEW 9REPAIR ❑ OTHER i <br /> .5. ❑ CHEMICAL TOILETS For July 1;'='June'30, 19 <br /> Type Construction....,. .._ Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 6 <br /> 6. C1 PACKAGE TREATMENT PLANT - Fcro' 1 <br /> .July ,•-June 30, 19 <br /> Operator Name f Where Certified <br /> Plant Location <br /> Plant Capacity �:•a No. Units Served <br /> 7. ❑ LAUNDRY For July.1,:June 30, 19 �V .9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Mope than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMO'. ' <br /> .y <br /> � S <br /> l hereby certify that I h ve prepared this applicat' nd that the work will be done in accordance with San Joaquin'County <br /> ordinances, state laws d rules and ulatio the oa in Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January•dl.._,. (];July 1 &"Received By July 31 <br /> ° BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED_ - AMOUNT <br /> FEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> --OTHER <br /> Received by Date Receipt No. Permit No, I Iss, ct Dalla M 'ied Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br />