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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application,
<br /> APPLICATION
<br /> I
<br /> (For Non-Transferable, Revocable,and Suspendable) c--:
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application rg.W made tory on si ss in the jurisdictional area of the San Joaquin_Local}�galth Di ncctt
<br /> rn Business Name ( ) Address ___-fie+
<br /> i
<br /> Owner ,- , Address � !1-
<br /> a
<br /> J Firm Partners, Addresses and Telephone Numbers —
<br /> m Business Telephone No. V cy Telephone No.
<br /> Contractor Licence No. -
<br /> Applicants Name (Print) .. Title r _ 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.
<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 StoredNo. 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. ❑ SANITATION PERMIT
<br /> Job Address/Location
<br /> Owner fil�� /C Address
<br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD AISEEPAGE 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 /> r
<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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> 14
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<br /> emnitl/pers.is s r;je:^r ro vrrr3cl�lnns Cl;;,r;,r�-,,1t1. . fay- c,-,air*:::.a_
<br /> I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, and le and r gulati sof the San Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31
<br /> REMIT
<br /> BILLING ', REMITTANCE $
<br /> EASE EXPLANATION i DATE REMITTED AMOUNT DUE CHECKED
<br /> DATE
<br /> AMOUNT
<br /> 1
<br /> FEE _` `
<br /> LESS i { r
<br /> PRORATION
<br /> PLUS Q�
<br /> PENALTY
<br /> OTHER
<br /> OTHER —�
<br /> Received by Date Receipt No, Permit No. ssuance ale Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201
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