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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 /> ENVIRONMENTAL HEALTH PERMIT Ss_PTAGE <br /> LIQUID WASTE <br /> Application is hereby m de to carryon bu ess,in t�hei'urisdictional area of the�S�as J aquin Local Health Distri t r l <br /> f y Business Name (DBA}L��.� 1 � � Addresses <br /> z Owner L,I- Address <br /> a — - <br /> J Firm Partners, Addresses a T I phone Num ers <br /> CL a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Ir <br /> Applicants Name_(Print} Title ate <br /> t <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1:• 0-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. Licc,,se Renewal No. <br /> Capacity—­—­— ,'^'"^ ,Gal`,Weights &Measures Na i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> NoA of'Chemical Toilets Stored <br /> 3. L❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test:Date/Time — <br /> 4. ❑ SANITATION PE IT <br /> f' pC r <br /> Job Ad r ss/Location <br /> Owner Address <br /> ❑,SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> I� ❑-PERMANENT TEMPORARY NEW ��EPAIR 11 OTHER <br /> 5. (❑ CHEMICAL TOILETS For July 1, -June 30, 19 t I <br /> Type Construction Disposal Site <br /> C No.of Units Equipment Storage/Cleaning Locafion(s) <br /> 6. '❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 1'9' i <br /> Il Operator Name # Where Certified <br /> i Plant Location s <br /> Plaint Capacity F ` 1. No. Units Served I v <br /> 7' ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- c <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> �_ <br /> I hereby certify t ave preparedIreul <br /> applic 'on and that the work will be done in accordance with San Joaquin County , <br /> ordinances, s 'laws, les d io s the. n aquin Local Health District: -- <br /> APPLICANT'S SIGNATURE <br /> t <br /> 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 /> BILLING! REMITTANCE $ -' iX REMIT <br /> BASE EXPLANATION AMOUNT DUE - CHECKED <br /> DATE ATE REMITTED AMOUNT y <br /> �. <br /> C FEa C t 0 TJ ? <br /> � E - �•i- •- - �.__, � . <br /> LESS _ x <br /> ' a <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> bn <br /> Received by Date Receipt NoPerrhit No. f1ssuaqceDlle ailed-j�' Delsv e - <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES -16x1 E-HAZELTON AV .Box 2009 STOCKTON,CA 95201 <br /> I '- <br /> i <br />