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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 /> L ENVIRONMENTAL HEALTH PERMIT SEPT/,—,° <br /> LIQUID WASTE <br /> Applicatio s ere y mad carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> �;Business Name (DBA) / 7� <br /> I- <br /> Owner . Address �`_ �/� �q� <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. <br /> _J Contractor Licence No. Emergency Telephone No. <br /> �Applicants Name (Print) <br /> o Title _ ��-� Date <br /> Please check Applicable Category ry (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. <br /> Capacity CAL. License Renewal No. <br /> 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 <br /> Test Location <br /> R.S. or R.C.E. No. <br /> 4. ❑ SANITATION PERMIT Test Date/Time <br /> Job Address/Location <br /> Owner <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL „IW,LEACHING FIELD <br /> ❑ PERMANENT ❑ TEMPORARYNEW SEEPAGE PIT ❑ PACKAGE PLANT <br /> Jk <br /> 5. 11CHEMICAL TOILETS For July 1, -June 30, 19 REPAIR ❑ OTHER O' <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 <br /> Plant Location Where Certified <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 No. Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> No raewnsrorIkeassQOpenlyaignslumcwtW4a0w :'!cM MAtiA�Aepb1101RIa11oN11i1tYr9rkhrtrillChtfI!t <br /> In such manner as to beci�me fJt eCl to worltnt3t�>C conpensafion lawe� penMi is issued,f shagttQten►ploranyperson <br /> Ceatraae m s subjkhVect <br /> or s a,Cti3Oys��mia fON `'EKY M►at ih1M e!0*wwk for Wlich fNis pe M1 is issued.I Shah <br /> ."'I,•e1�persons sutyecf to wurkmads comper�safiQnfa�ws Di.,.»�...��6a” <br /> I hereby certify that I have prepared appIicat' J <br /> n and that the work will be done in accordance with Sanoaquin County <br /> ordinances, state laws, and rules a re ulations the San Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X 0� I, <br /> i <br /> FOR DEPARTMENT USE ONLY IT <br /> Fee IS Due: 1:1 ANNUALLY PER UNIT <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received B Januar <br /> By Y 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> � <br /> PRORATION SO <br /> PLUS PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rey//�� �o <br /> ed byuate <br /> Receipt No. Permit No. Issuance vate <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered <br /> 1601 .HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />