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i <br /> 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 SE PTAGE <br /> LIQUID WASTE , <br /> er 0-T <br /> Application is eb made to,cbrry business tri the jurisdictional area of the S n Joaquin Locp �ealth District <br /> F BusI5esANa e (DBA " � n <br /> Address <br /> za Own <br /> Address O L�C�r�Zc•� �� <br /> gr <br /> Firmners, Addresses and Telephone rs <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) �� Title Dale <br /> Please check Applicable Category (1-7) and Fill in the Required Iniormation <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 w ' <br /> 2. ❑ PUMPER YARD. - i�..rs-w �. >w .} +, �r.�rrK•i ..r.R.e�r�...«� #"`9�1, <br /> For July.1-, - June 30, 191 <br /> No. of Vehicles Stored t s <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST 1 _ <br /> R.S. or R.C.E. Name _. - - =_ '�^' a'"-` R.S.-or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. .9 SANITATION PERMIT <br /> Job Address) ovation <br /> Address <br /> SEPTI TANK 11E <br /> CESSP~ L AACCHING FIELD,,❑ E AGE PIT ❑ PACKAGE PLANT <br /> 4 -PERMANENTS,• -0,T-EMP ORARY '^ -N�w t IREPAI O'OTHER "" w <br /> . . �. d <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units ! Equipment Storage/Cleaning Location(s) <br /> i <br /> fi. © PACKAGE TREATMENT PLANT For July-1, -June 30, 19 �i. <br /> Operator Name _.r Where Certified <br /> Plant Location <br /> ( y <br /> . # No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -rJune 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq;Ft., El ore Than 1,00 Sq. Ft. <br /> µ _ � 1 9 <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 Countyi <br /> s ordinances, state laws, and rules a gul ions sof the San Jo uin Local Health District <br /> y k <br /> 6 } � <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 'S`b <br /> rr i <br /> Fee Is Due: ❑'ANNUALLY ❑ PER UNIT .'❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> s f � � REMIT <br /> BILLING. REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE - EXPLANATION - DATE TE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> I PLUS T <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> og <br /> ece <br /> Date Ript No. Permit No. Issuance Date Mailed Delivered <br /> Received by <br /> ,. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />