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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 Suspendabie) <br /> 5EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicata is hereb made to car -on business in the jurisdictional area of the San Joaquin ocal He I Is t <br /> F Business Nam DBAj a Address— ��S i ��' <br /> aOwner �4 &- � Address <br /> J Firm Partners, Addresses and Telephone Numbers �- <br /> CL a Business Telephone No. �' �Gil Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ( For Juiy 1, June 30, 19 4 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Seriai No. rCAL. 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. ' <br /> Test Lopation Test Date/Time 31 <br /> 4. ®/SANITATION PERMIT <br /> Job Address/Locati <br /> w r — - , ddress O <br /> M�QIIr <br /> PTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> f PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> k 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> L <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 /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 ' <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, rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received B'y January 31- ❑ July 1 &Received By July 3i . <br /> REMIT <br /> r BICEING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED'-�- AMOUNT DUE CHECK EO <br /> k U AMOUNT <br /> I FEE 4 L � ,- <br /> ( LESS 1 <br /> PRORATION <br /> PLUS <br /> ( PENALTY n 1 <br /> OTHER <br /> �- OTHER -- <br /> a &?Oq <br /> Received by 'Date .e..,.Receipt;NoPermit No. scan a Date Mailed Delivered <br /> I -- 'APPLICANT—RETURN ALL COPIES'TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES R� 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 <br /> 6,A~ m iryeA <br />