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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) $EpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i0ereby made to carry on business i the uris tional area of the San�� in L/g�'al H��district �� <br /> Address T <br /> H Business Name(O � n t" <br /> Address <br /> 4 Owner <br /> J Firm Partners.Addresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. �� �'�OS g <br /> a 11111,��Z <br /> Contractor Licence No. 111',7 <br /> pate — y <br /> Title <br /> Applicants Name (Print) + ' <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) CAL. Licc.ise Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity 4 `' Lti Gal.,Weights &Measures No. <br /> Equipment Parking AddressT <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST "" <br /> R.S.-or R.C.E. No. <br /> R.S. or R.C.E. Name t <br /> ....._�— <br /> Test�' cation Test Date/Time <br /> 4. rJ SANITATION PERMIT <br /> k. Job Address/L tionOwnei <br /> Address _ <br /> 1; ❑ SEPTI TANK ❑ CESSPOOL ,LEACHING FIELD SEEPAGE PIT - ❑ PACKAGE PLANT <br /> 11 ❑ PERMANENT ❑ TEMPORARY '❑ NEW U2PREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -r une 30, 19 r <br /> Type Construction_ I Disposal Site <br /> No. of Units 1 Eq`ipment�SiorageYCleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> .. �i-` _ .. Where Certified <br /> Operator Name <br /> ?�r - <br /> Plant Location - 9 <br /> Plant Capacityy " No. Units Served <br /> T. ❑ LAUNDRY For July-1,'-June 30, 19- <br /> 16 - <br /> 9 - <br /> SIZE: 11 Less Than 1,000'Sq. Ft.,­❑ More Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I / i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regul tions of the San Jo a uin Local Health District. <br /> rI <br /> APPLICANT'S SIGNATURE X <br /> tr <br /> 0rPER <br /> DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LAPER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I FEE <br /> 1/5 y y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I Received by Date Receipt No Permit No. Is uance Dale Mailed D livered <br /> I evr v o Hoz 20D9 STOCKTO .CA 95201 <br />