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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 PERMITt n I�'�� <br /> LIQUID WASTE <br /> Application is reby made to ar on busi ess in th 'urisdictional area of the San Joaquin Local Health Distrlc <br /> UF) Business Nam BA) Address Q�z`'-►• 76 7 <br /> z Owner Address <br /> a <br /> n Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 3z- ��l 0 Emergency Telephone No. <br /> Contractor Licence No. 3 <br /> L Applicants Name (Print) — a 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 /> r <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 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�LL tion Test Date/Time <br /> 4. 1 SANITATION PERMIT <br /> Job Address/Location V V.12 <br /> Owr ❑ PACKAGE PLANT Address <br /> r <br /> 3-7 <br /> SEPTIC TA K CESSPOOL LEACHING FIELD SEEPAGE PIT O <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 J <br /> Operator Name Where Certified N <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. Ilk 1l,'Ax <br /> I hereby certify that I have prepared this application and that the work will be done in cordance with San Joaquin County <br /> ordinances, state laws, and rules an ulations of the n o quin Local Health Distr' <br /> APPLICANT'S SIGNATURE X 9 <br /> FOR DEPARTMENT USLY <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH latay 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING R TTANCE $ AMOUNT DUE CHECKED <br /> DATE i DATE REMITTED AMOUNT <br /> O <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �-5 s ,y <br /> Received by Date Receipt,No. Permit No. I u c at Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.-HAZEL E.,P.O.Box 2009 STOCKTON,CA 95201 <br />