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Applications Will Be Processed When Submitted Properly Completed. Be Sul Sir (1'e l�pLplicaij , <br /> LW <br /> APPLICATION II }} 11 �j <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH,PERMIT SAS! J0 ',Ql5Ei p.�TAL3,-AL <br /> LIQUID WASTE HEALTH DISTRICUT <br /> Application is hereby. ade to carry on business in the jurisdictional area of-the San Joaquin Lorie Istrictf <br /> yBusiness Name (DBA).4%A <br /> Business Addressda4['�1 �- ��® <br /> z OwnerAddress <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. ������! Y Emergency Telephone No: _ <br /> 961777 <br /> Contractor Licence No. - 1 <br /> L Applicants Name (Print) Title WWI 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 /> I 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 <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. ❑ SANITATION PERMIT �/y b <br /> Job Address/Location ' t <br /> Owner t Address <br /> ❑ <br /> �SEPTIC TANK 11 CESSPOOL, �LEACHING FIELD ❑ SEEPAGE PIT' PACKAGE PLANT <br /> f <br /> X PERMANENT 13 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 /> 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. - r <br /> I hereby certify that I have prepared thinttikohe <br /> "µ ation'and that the work will be done in Zaccor4dn�Lcewith San Joaquin County <br /> ordinances, state laws, rules an regul SanJoaquin Local HealthDistrict. <br /> . <br /> APPLICANT'S SIGNATURE X <br /> - m FOR DEPARTMENT USE-ONLY- <br /> Fee <br /> SE ONLY-Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31: ❑ July 1 &Received By July-31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED , <br /> s DATE DATE REMITTED 'AMOUNT <br /> " FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Llate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BCx 2009 STOCKTON,CA-95201- <br />