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mIlnnlcaaonsWillBe Processed When Submitted Properly Completed,Be Sure To Sign The Appl!tion. <br /> APPLICATION - <br /> [_{, (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT /�SEPTAGE <br /> LIQUID WASTE <br /> r Application is hereby made to carryon bus'ness in he'urisdictional area of the an Joaquin L caLHealth Distric <br /> H Business Name (DBA) ��)� i �-U�' t !� f <br /> a Owner L�� �L LIq i T t1 r Address <br /> — <br /> j Firm Partners, Addresses a Telephone NumbersAddress <br /> aBusiness Telephone No. <br /> Contractor Licence No. Emergency Telephone No. <br /> a <br /> L Applicants Name(Print) <br /> Please check Applicable category(1-7)and Fill in the Required Information Title <br /> 1• 0 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) Date <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) Disposal Sites <br /> Serial No. <br /> Capacity CAL. License No. <br /> Gal., Weights&Measures No. CAL.License Renewal 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 <br /> Test Location R.S.or R.C.E. No. <br /> 4. ❑ SANITATION PERMIT Test Date/Time <br /> Job Address/Coca ion S <br /> Owner <br /> SEPTIC TANK ❑ CESSPOOL Address <br /> ❑ PERMANENT ❑ EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> TEMPORARY NEW <br /> 5• ❑ CHEMICAL TOILETS For Jul 1, - ❑ REPAIR ❑ OTHER <br /> Y June 30, 19 <br /> Type Construction <br /> No. of Units Disposal Site <br /> s• 11 PACKAGE TREATMENT PLANT <br /> Equipment <br /> ment Storage/Cleaning Location(s) <br /> Operator Name Y June 30, 19 <br /> Plant Location <br /> Where Certified <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For.July 1, -June 30, 19No. Units Served <br /> SIZE: ❑ Less Than.1,000 S Ft. ❑ <br /> 9 , More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify thave prepared this applicati <br /> ordinances, state and that the work will be done in accordance with San Joaquin County <br /> laws a rules and gula ' ns o t e San Joaquin Local Health District. <br /> 1PPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT LSE ONLY <br /> Fee Is Due:❑.ANNUALLY ❑ pER UNIT <br /> Q PER SITE ❑EACH ❑ January 1 &Received By January 31 V <br /> BASE EXPLANATION BILLINGREMITTANCE El July 1 &Received By July 31 <br /> DATE $ REMIT <br /> DATE AMOUNT DUE <br /> FEE � �'e� REMITTED CHECKED <br /> J _ <br /> LESSAMOUNT <br /> s <br /> PRORATION -- <br /> PLUS <br /> PENALTY S <br /> OTHER <br /> OTHER <br /> Receiv <br /> D e Receipt No. Permit No._ <br />-- APPL NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVI6ES0 <br /> Issuance Date Mailed <br /> 1901 E.HAZELTON AVE.,P.O.Box 2 KTO <br /> 009 STOCKTON,CA 95201 . <br />