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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 SEEPAGE <br /> LIQUID WASTE <br /> Application i hereby mad c2n�Dnbusiness in V jurisdictional area of the San Joaquin Lo Health District <br /> ,F Business Name DBA) Address +` <br /> rOwner _ Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, Emergency Telephone No. <br /> Contractor Licence No, <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information C."J <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, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I, No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. c <br /> Test Location I ATe t Date/Time r— <br /> r 4. SANITATION PERMIT / !r <br /> Job Address/Location (A- T Ate_-�°J� $?ca.>±�L HA I rou&& 0�& 4t,4gm St <br /> Owner Address <br /> l %­6EPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ,&SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1P—PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, s d re lations f the San J aqui cal Health District. <br /> APPLICANT'S SIGNATURE X 1 <br /> OAaa— <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece-ived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> r FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> - PENALTY - <br /> I OTHER <br /> OTHER <br /> 0 �C) <br /> Received by Date I Receipt No. Permit No. Issuance Date ailed Delivered <br /> 4 <br /> APPLI CANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 116011 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA.952p1 <br />