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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 /> 174— <br /> !{ ENVIRONMENTAL HEALTH PERMIT SPTAGS <br /> LIQUID WASTE <br /> Applicatio Is by madery on business in the jurisdictional area of the San Joaquin Leal alt D' rict <br /> ,„Business Na a (DBA) � Address <br /> aOwners r/��7i7,t ,__L'�' Address 1 `� <br /> J Firm Partner's, Addresses and Telepho a Numbers <br /> RL Business Telephone No. 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 /> 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. Licc Ise 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT .^1 <br /> Job Address/Location +� ` (J <br /> �O er Address <br /> EPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ 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 /> 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 /> P> <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, an rules d r lation San Joaquin Local H Ith District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMEa 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMPUNT <br /> FEE '�� L-/ _ <br /> LESS } [ <br /> PRORATION <br /> PLUS <br /> PENALTY L <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit. Issi.1lanceDat6s Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />