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Applications Will Be Processed When Submitted Properly Completed. Be Sure 1oalgn Inr.,NNr�a.,., • <br /> APPLICATION u <br /> r (For Non-Transferable, Revocable,and Suspendable) f <br /> SEETAGE <br /> ENVIRONMENTAL HEALTH PERMIT o <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District V <br /> ,F Business Name (DBA) • � Address <br /> z Owner Address <br /> e <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> 4 <br /> Contractor Licence No. 33y 71 �! <br /> Title <br /> L Applicants Name (Print) <br /> 1 -Date <br /> — _ I <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. License Renewal No. <br /> Serial No. CAL. License 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 /> No. of Chemical Toilets Stored 4 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.O.E. No. <br /> Test Location Test Date/Time <br /> �r <br /> 4. 3? SANITATION PERMIT <br /> Job Address/Location 7" <br /> Owner ,,fid_0VAd L€+1' AtilleY # Address <br /> SEPTIC TANK [I CESSPOOL LEACHING FIELD ❑ ❑ PACKAGE PLANTSEEPAGE PIT 11 OTHER <br /> PERMANENT 11 TEMPORARY �i NEW, ❑ REPAIR <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity 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. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. �r <br /> . II <br /> ,l <br /> I hereby certify that I have prepared this application and t e rk will be done in accordance with Sari Joaquin County <br /> ordinances, state laws, and rules and regulati s of the Sa Joaquin oval 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 31 ❑ July 1 &ReceiveRdEByl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT,OUE CHECKED <br /> DATE DATE, REMITTED AMOUNT <br /> FEE . <br /> .I <br /> LESS <br /> PRORATION <br /> PLUS ly <br /> PENALTY <br /> i1 <br /> OTHER <br /> OTHER <br /> . 1 �5 �3 ��►oma 1 17 j ,{•,. ,r -r/ I <br /> Delivered <br /> Received by Date Receipt o. Permit No issuance Date Mailed <br /> - • <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PfRM1TlSERVICES - <br /> 1691 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />