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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SE PTAG E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is he eby made to carry on business in the jurisdictional area of the.San Joaquin Local Health District <br /> NBusiness Name (DBA) Address <br /> aOwner ' .. Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> IL a Business Telephone No. -� Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) Title u3, -- Date <br /> Please check Applicable Category (1-7)and fill In the Required Information -,; I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> iFor July 1, June 30, 19 `'° Disposal Sites i <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 i_ ` <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored j <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 /> Nest Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT t <br /> Job Address/Location <br /> OwnerAddress <br /> 1445 <br /> 13"�EPTiC TANK 1:1 CESSPOOLX LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> •❑ PERMANENT ❑ TEMPORARY ❑yNEW f ❑"REPAIR ❑-OTHER <br /> ;5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 4 <br /> Type Construction h Disposal Site <br /> No. of Units Equipment Storage/Cleanin"g Location(s) <br /> .6. ❑ PACKAGE TREATMENT PLANT For­July 1, -June 30, 19/, <br /> Operator Name i Where Certified 0 <br /> Plant Location <br /> I No. Units Served t`a <br /> 'Plant Capacity - <br /> 7. ❑ LAUNDRY For July 1,-June 30-,,19­w <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 have prepared this application and'that the %kork'will be done in accardanye=w'rth San Joaquin County <br /> ordinances, state_ laws, and rules and regulatio 9 of t e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` w <br /> FOR DEPARTMENT USE ONLY *�3 <br /> Yt <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ FAG" '�•❑ January 1&Received By'January 31 ❑ July 1 &Received By July 31 <br /> r i REMIT <br /> I <br /> BASE, PLANATION <br /> BILLING f �REM{TTANCE - AMOUNT DUE CHECKED <br /> kDATE - - .* ATE .�RFMITTED AMOUNT - <br /> b ..FEE.. -�- t - - - __ - �• <br /> i <br /> LESS aL <br /> PRORATION - - <br /> "'PLUS ,-��+.--.�,.....y- - ^/ - „�._ .,., .�._,�.^.-' - -.r•.-f...» n,. ��r—�..1�-. - <br /> R <br /> PENALTY <br /> I OTHER 49 t4 � q I ► _ ; <br /> ~� <br /> ` S7 'Eh, •'�"� l�,+a., i " , <br /> E Received by aI"< Date d L +,. Receipt No ; ± `. Pe`Tit No. * y;.Rks�s anc Dale i Malled' Delivered <br /> T-_RETURN ALL COPIES TO: -`ENVIRONMENT�AyL HEALTH PERMIT/SERVICES 1601 E:HA`TON AVE,P.O.Box 2009 STOCKTON,'CA 95201 <br /> !. fes` b <br /> _ \ r <br />