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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION , <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG! <br /> LIQUID WASTE <br /> Application is h eby made to arty on business in the juri fictional area of the SW Joaquin Local Health District, <br /> w Business Name (OBA} _ Address--fl ��t}- 7 <br /> Owner - Address <br /> J Firm Partners,Addresses and Telephone Numbers <br /> C6 <br /> Business Telephone No. -._ �, U � 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 Ipformstion U\ <br /> 1. ❑ PUMPER-VEHICLE PERMIT,REGISTRATION(FOR EACH VEHICLE) <br /> For: y 1,`tY "June 30**19:3�• Disposal Sites <br /> Description(Make/Yr.,Calor)_ "% <br /> Serial No. ~ w e CAL. License No. CAL. License Renewal No. <br /> - <br /> ' <br /> Capacity ' A "*Gal,,Weights&Measures No. <br /> Equipment Parking,Addr6ssy""' <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, ne�30 X19 <br /> No.of Vehicles Stored + <br /> No.of Chemical-.Toilets Stored <br /> 3. ❑ PERCOLATION TEST j <br /> R.S.or R.C.E.Name T R.S.or R.C.E.No. <br /> Test Location I Test Date/Time - <br /> I 4. ❑ SANITATION PERMIT <br /> Jodress/Location <br />( O er ' Address r � <br /> SEPTIC TANK 0 CESSPOOL LEACHING FIELD Ell-PA'CKAGE-PLANT <br /> i ❑ PERMANENT ❑ TEMPORARY ❑ NEW EPAIR ❑ OTHER &I <br /> 5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction It Disposal Site <br /> + !r <br /> No.of Units Equipment Storage/Cleaning Location(s) � f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30. 19 I <br /> Operator Name ft Where Certified <br /> Plant Location <br /> Plant Capacity LOW,— No.Units 15ervwd r <br /> 7. ❑ LAUNDRY For July 1,-June 30,x19.'.. I <br /> SIZE: 0 Less Than 1,000 Sq. Ft., j0'More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. 410% <br /> 7 <br /> I hereby certify that 1 have prepare is application and that the.work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rul drs gulations of the San Joaquin Local Health District. w <br /> APPLICANT'S SIGNATURE <br /> Joe <br /> f r <br /> r� <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dtie: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 13'EACH ❑ January 1&Received By'January 31 ❑ July I&Received By JUIy 31 <br /> 1 BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION GATE {]ATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L45 - r4--f S <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY t <br /> OTHER r <br /> OTHER r <br /> r <br /> o ss y 3 .'A ,-G NO <br /> Received by pate Receipt No. Permit No. IsisdanoeDalee NMajied Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AV .O:Box 20011 STOCKTON,CA 915201 <br />