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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign'IllpApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) 7 641- <br /> ENVIRONMENTAL <br /> 41-ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio Is hereby de to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) I o � c � � Address f ds 1 �"f T— <br /> 7' <br /> i Owner /f 14 411 �P, Address ° .' ------ <br /> aI If <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q. Business Telephone No. yl s_2GIL Emergency Telephone No.—_��-- <br /> Contractor Licence No. 3fS —-- - <br /> Applicants Name (Print VZ& Title —71 <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 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 Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/L ation - <br /> i,� ��S Address e rJfG' � r /?---- <br /> • <br /> --,Q f <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANC <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 /> Where Certified <br /> Operator Name <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 /> I hereby certify that I _prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I s, an rul and regulations of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X" 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <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 />