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Applications Wili-Be-Pi,66&5ed When Submitted Properly Completed. Be Sure To Sign The Application. , <br /> APPLICATION <br /> J (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SPTAG <br /> LIQUID WASTE <br /> Applicatio hereby ma o carr 9�bus i ss in toe jurisdictional area of the San Joaquin L 4al H !t i <br /> O Business Na a DBA) Addres 4 s <br /> i Owner <br /> a Address <br /> Firm Partners, Addresses and/Lelephone Numb rs <br /> aBusiness Telephone'No.7 ` r�nl Emergency Telephone No. <br /> Contractor Licence No. d� <br /> LApplicants Name {Print)- !. t Title s� Date /lJ <br /> Please check Applicable Categliry (1-7)and Fill in the Required.lnformation <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. J <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 IM ► k t <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 /> r <br /> 4. PfSANITATION PERMIT <br /> Job Addres /Locatjo E' <br /> Owner C �ioAddress , <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ` <br /> 11 PERMANENT,' <br /> 11 TEMPO RARY ❑ NEW 11 REPAIR 11 OTHER f <br /> r <br /> 5. ❑ CHEMICAL TOILETS For.July 1, -June 30, 19 t <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 6 <br /> Operator Name Where Certified I +4. <br /> Plant Location �N <br /> Plant Capacity 1 t No. Units Served f #! <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> ' I - I : <br /> SIZE: '�.❑ Less Than 1,000 Sq. Ft.,� El More Than 1,000 5q. Ft. <br />! ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the;wyr�k 4wilf be done in accordance with San Joaquin County j <br /> ordinances, state laws, a and regulatio s of the Sa Joaquin Local Health District. ! <br /> 1*1 a t r <br /> ` <br /> APPLICANT'S SIGNATURE X <br /> t <br /> !► FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY �❑ PER UNIT ❑ PER I ' <br /> 4 ! SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> j <br /> - SASI REMIT I EXPLANATION BILLING REMITTANCE $ <br /> ! DATE DATE REMITTED AMOUNT DUE CHECKED- <br /> t���* ,, ( Lv AMOUNT I <br /> >14fiEE�. « . F'S O C <br /> LESS1 <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> OTHER77 <br /> �! <br /> Received by Date IY Receipt No. Permit No ssuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - .1661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTDN;CA 95201 <br />