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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) I <br /> _ ENVIRONMENTAL HEALTH PERMIT SEPTAOE <br /> LIQUID WASTE <br /> Appl ica ion is hereby made to car n business i e jurisditional area of thaSan Joaquin` Ic Loc�ealth District_ <br /> F Business Name(DBA) o s� d ��� <br /> ress -..- `�-- � <br /> z Owner�� F � (a L ALL_ ,Address `�. , J <br /> L) Firm Partners, Addresses aAd IThone Numbers <br /> aBusiness Telephone No. S'. Emergency Telephone No. �— <br /> j Contractor Licence No. S <br /> �Applicants Name (Print) Title Date EM <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> " 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> f For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. .,!CAL. License No. GAL.Lice se Rens al No. <br /> r <br /> Capacity - tGal: Weigh ts.&'Measures-No. <br /> Equipment Parking Address <br /> k 2. ❑ PUMPER YARD <br /> "_For July 1, - June 30,19 <br /> No. of Vehicles Stored <br /> No. 6f-Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E..Narrle <br /> + R.S. or R.C.E. No. <br /> Test Location Test-Date/Time <br /> i 4. ❑ SANITATION PERc <br /> Job Addrgs /Location <br /> Owner lr : Address <br /> I ❑ SEPTIC TANK ❑ CESSPOOL EXLEACHING FIELD —❑ SEEPAGE PIT ❑ PACKAGE PLANT ' Ic <br /> f ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER ` <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t Q <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) F <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name i Where Certified <br /> fPlant Location <br /> Plant Capacity No. Units Sewed <br /> f _ f <br /> 1 7. •❑ LAUNDRY For July 1, -June 30, 19 - <br /> SIZE: ElLess Than 1,000-Sq. Ft., ❑ M-6-re Than 1,000 Sq._Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> h <br /> a <br /> t .. <br /> I hereby cert t I have prepare this applicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, St to la and r es nd gulag ns of 'h San J qui oval Health District. <br /> APPLICANT'S SIGNATURE <br /> Xel <br /> / Q ' <br /> FO DEP RTMENT USE ONLY <br /> w ' <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> / � AMOUNT <br /> FEE �✓ `C� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> !a[ho 3o-I `� I <br /> Received by - Date Receipt No. Permit No Issuance Date Mailed Delivered i <br /> APPLICANT—RETURN ALL"COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA <br />