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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 Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,A \ LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) s.+ .. ,.. 't_ ? Address_-_aa t •.,-_ ` >.,et Y a --- <br /> z Owner ___ - - -- Address--.- <br /> Firm <br /> ddress _._Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. `f "L -'t -% ______...__ Emergency Telephone No. <br /> a — <br /> Contractor Licence No _ — <br /> L Applicants Name (Print) Fa,!._. `= :.,.. Title` A _��`L:.. 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. �1 <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 /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location - Test Date/Time —. <br /> 4. E'SANITATION PERMIT <br /> Job Address/Location ""t -` �_I__ £_s- - L -- -•' <br /> _.. <br /> Owner L '_ -.f Address <br /> SEPTIC TANK ❑ CESSPOOL (] LEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ 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 /> s <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. F< <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. — — -- <br /> to <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, nd,rules and regulations of the,Sah JOB uin.Local.Mealth District. <br /> APPLICANT'S SIGNATURE X —' - f <br /> FOR DEPARTMENT USE ONLY <br /> 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 /> DATE DATE REMITTED AMOUNT <br /> t-= G <br /> FEE -'-"`- <br /> LESS v <br /> PRORATION <br /> PLUS------- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance 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 />