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Applications Will Be Processed When Submitted Properly Completed. SeSureToSign <br /> APPL'ICATION ' <br /> (For Non-Translerable,'Revocal 61 rind Suspendable) gFPTAGE <br /> ENVIRONMENTAL HEALTH;PERMIT <br /> LIQUID WASTE r <br /> Application is hereby maA to carry on business in the jurisdictional area of the San Joaquin Local Health•District% 04 <br /> J <br /> €pr�l 1 A( T'�12�l R� Address ++' <br /> Business Name (DBA) ` 3 <br /> ri <br /> OwneAl .. Address <br /> r _ . . <br /> Firm Partners,'Addresses and Telephone Numbers �s <br /> Business Telephone No. 'S3S � 7B F Emergency Telephone No; <br /> Contractor Licence No. -x <br /> Applicants Name (Print) 144 Title Date <br /> y j <br /> Please check Applicable Category (14).and Fill in the Required_Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) k <br /> For July l,- - !�June30, 19- '- Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. 11 <br /> Serial No. CAL. License 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 w <br /> 3. .❑ PERCOLATION TEST R.S. or R.G.E. No. <br /> R.S.or R.C.E. Name <br /> Test ovation Test Date/Time <br /> 4. SANITATION PERMIT14 <br /> �.3 O <br /> Job Address/Location <br /> , <br /> OwnerAddress <br /> 11 SEPTIC 1SEPTIC TANK CESSPOOL �LEAGHING FIELD ❑ 13 PACKAGE PLANT <br /> SEEPAGE PET� JN SEEPAGE <br /> J.->R4 lIV <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWREPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> Type Construction 7?A! Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i 6. 11 PACKAGETREATMENT PLANT For July i, -June 30, 19 <br /> Where'Certified <br /> 'Operator Name <br /> Plant Location'. '- ? No. Units Served <br /> ;Plant Capacity <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 /> T in accordan i wi a Jo ~in <br /> hereby certify that I have prepared this application and that the work will be done �' <br /> ordinances, state laws, d rules a r�d regul O s of'the-San Joaquin Local Health District. <br /> 1 'APPLICANT'S SIGNATURE, <br /> ^p <br /> F k FOR DEPARTMENT USE ONLY - <br /> Fee IS Due: ❑ ANNUALLY [IPERUNIT El PER SITE <br /> EI ❑ January i &Received By January 31, ❑ July 1 8 Received July-31 <br /> E I <br /> - !EXPLANATION BILLING t REMITTANCE AMOUNT DUE CHECKED <br /> BASE <br /> _ _ DATE DATE -REMITTED AMOUNT <br /> 1 FEE <br /> i <br /> LESS t <br /> - PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER . ' <br /> OTHER - -. - <br /> V w s u nc ate M I d• Delivered <br /> ' Received by to 'Receipt No:- Permit No. r . <br /> - 1fi01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- <br />