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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> L (For Non-Transferable, Revocable,and Suspendable) <br /> 5EP7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Address 4645 Hi ridrA+ �— 3e <br /> z Owner Address €v-k�fro <br /> a <br /> Firm,Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, q � q�7 Emergency Telephone No._� 7 <br /> Contractor Licence No. 13 <br /> L Applicants Name {Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 01) <br /> +` <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites w <br /> Description(Make/Yr., Color) <br /> Serial No. CAI_. 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 /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> t R.S. or R.C.E. Name r R.S. or R.C.E. No.� <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT r ;' <br /> Job Address/Lo Torr- j! NEW <br /> Owner ddressSEPTIC TANK CESSP OLLEACHI FIELD SEEPAGE PIT 11PACKAGE PLANT <br /> PERMANENT ❑TEMPORARY REPAIR OTHER <br /> 5. 11CHEMICAL TOILETS For July 1, a 30, 19 (n <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 <br /> No. Units Served <br /> 7. Cl 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/AmouriT/M x LL <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 rul nd r ulation San Joaquin Lo I Hea District. ` <br /> APPLICANT'S SIGNATURE X <br /> 7 <br /> t 41 <br /> f . FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &deceived By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r 1 - <br /> FEE ' r 4 <br /> LESS <br /> PRORATION <br /> PLUS s . <br /> PENALTY ! — <br /> OTHER <br /> OTHER <br /> 4 - Received by Date Receipt No- Permit Ne. I suanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />